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Full text of "Eye, ear, nose, and throat nursing"

NURSING 
EYE, EAR, NOSE 

AND 

THROAT DISEASES 



DAVIS -DOUGLAS 



^.SENTED Tq 



S.2Z 



The New ¥ 




of Medicine 



By 



NATIONAL LIBRARY OF MEDICINE 
Bethesda, Maryland 

Gift of 

The New York Academy of Medicine 




WITHDRAWN 

MAY 8 2009 

THE NEW YORK ACADEMY 
OF MEDICINE LIBRARY 



Eye,Ear,Nose,andThroat 
Nursing 



A. EDWARD DAVIS, A.M., M.D. 

Professor of Diseases of the Eye* in^the New York Post-graduate Medical 
School and Hospital 

AND 



BEAMAN DOUGLASS, M.D. 

Professor of Diseases of the Nose and Throat in the New York Post- 
graduate Medical School and Hospital 



V7 



SECOND REVISED EDITION 



WITH 32 ILLUSTRATIONS 



HE N. Y. ACAD 

JAN 12 1921 
I L loKAni 

PHILADELPHIA 

F. A. DAVIS COMPANY, Publishers 
1920 




COPYRIGHT, 1905 
COPYRIGHT. 1920 
BY 

F. A. DAVIS COMPANY 

Copyright, Great Britain. All Rights Reserved 




PRESS OF 
F. A. DAVIS COMPANY 
PHILADELPHIA, U. S. A. 



PREFACE TO SECOND EDITION. 



In the second edition of this little volume every chap- 
ter has been carefully revised, new matter incorporated 
and an entirely new chapter on Vaccine and Serum Treat- 
ment added. As stated in the first edition this book is 
meant simply as a guide for nurses and students in the 
care of the various diseases of the eye, ear, nose, and throat, 
and to instruct the nurse as to her exact duties during and 
following operations upon these organs. We trust that it 
may continue to be useful and a safe guide in her hands. 

A. E. D. 

B. D. 

New York. 



(iii) 



PEEFAOE TO FIEST EDITION. 



While this little book has been written primarily for 
the use of nurses, students and general practitioners will, 
we believe, find it of great assistance to them also. It is 
not a treatise in any sense of the word, but is meant simply 
as a guide for the intelligent care and nursing of the vari- 
ous diseases of the eye, ear, nose, and throat, and to in- 
struct the nurse as to her exact duties during and follow- 
ing operations upon these organs. 

Antisepsis and asepsis have received particular atten- 
tion, since, above all, the nurse should know the all-impor- 
tance of surgical cleanliness. The methods of preparing 
the numerous antiseptic and sterile solutions and dressings 
have been given in detail, while the various remedies re- 
quired in the treatment and nursing of these special 
organs, their preparation, sterilization, and exact method 
of application, have been considered fully and most care- 
fully. In fact, we have endeavored to show the nurse how 
to do things and correctly, because, in treating such deli- 
cate organs as the eye, ear, nose, and throat, the good 
results obtained depend fully as much upon the intelligent 
and painstaking care of the nurse as upon the work of the 
physician himself. 

A brief outline of the anatomy and physiology of the 
eye, ear, nose, and throat has been given, in order that the 
nurse might better understand the subjects under con- 
sideration. 

Dr. Davis has written the chapters on the eye; Dr. 
Douglass, those on the nose, throat, and ear. 

A. E. D. 

New York. 

13. JJ. 

(iv) 



CONTENTS. 



Part I. — Nursing of Eye Diseases. 



CHAPTER I. 

Necessary Requirements for Special Nursing; Anatomy 
and Physiology of the Eye. 

page 

Necessary Requirements 1 

•Eyebrows 3 

Eyelids 3 

Lacrymal Apparatus 4 

Ocular Muscles & 

Conjunctiva @ 

Cornea » 

Sclera „■ • * 

Aqueous Humor 8 

Vitreous Humor 8 

Crystalline Lens 8 

Uveal Tract J 

Choroid 9 

Ciliary Body 10 

Iris J| 

Retina 

Optic Nerves - 

Orbits J J 

Eyeball JJ 

Accommodation ~* 

Binocular Vision 

CHAPTER II. 

Contagious Diseases of the Eye. 

Definition of Contagion and Infection 15 

Germ Theory of Disease J j» 

Epidemic and Endemic J 7 

Antisepsis and Asepsis " j« 

Catarrhal Conjimctivitis ±° 

Gonorrhoeal Conjunctivitis *7 

Ophthalmia Neonatorum 34 

(v) 



vi CONTENTS. 

CHAPTER III. 

Membranous Conjunctivitis (Croupous and Diphtheritic). 

page 

Membranous Conjunctivitis 38 

Croupous Conjunctivitis 38 

Diphtheritic Conjunctivitis 40 

Traumatic Membranous Conjunctivitis 44 

CHAPTER IV. 

Noncontagious Diseases of the Eye. 

Hordeolum 47 

Blepharitis Marginalis 47 

Phlyctenular Conjunctivitis 49 

Ulcerative Keratitis 52 

Iritis ■> 55 

Cyclitis 56 

Iridocyclitis 56 

Sympathetic Ophthalmia 57 

Glaucoma 61 

Panophthalmitis 63 

CHAPTER V. 

Remedies and their Application. 

Antiseptics 65 

Astringents 70 

Anodynes 75 

Irritants 75 

Counter-irritants 77 

Caustics 78 

Mydriatics and Cycloplegics 78 

Myotics 83 

Anesthetics 85 

Miscellaneous Remedies 87 

Bloodletting 90 

CHAPTER VI. 

Remedies and their Application (Continued) . 

Drops 92 

Lotions and Solutions 96 

Solids 101 

Powders 102 

Ointments and Salves 103 

Heat 103 

Cold 105 



CONTENTS. 



vii 



PAGE 



Subconjunctival Injections 106 

Mechanical Remedies 107 

Hypodermic Injections 108 

Diaphoresis 109 

Hydrotherapy 109 

Diet 110 

Rest Ill 

CHAPTER VII. 

Serums and Vaccines. 

Serums and Vaccines 113 

Diseases of the Lids 115 

Conjunctivitis 115 

Keratitis 116 

Diagnostic Reactions 117 

Therapeutic Reactions 122 

Other Vaccines, Serums 123 

Preparing the Patient 124 

Syringes 124 

Site of Inoculation 124 

Reactions 125 



CHAPTER VIII. 

Operations on the Eye. 

Antisepsis and Asepsis 

Arrangements for Operations . . 

Operating Room 

Instruments 

Dressings 

Suture Materials and Ligatures 

Disinfecting the Hands 

Preparing the Patient 

Field of Operation 

The Different Operations 

CHAPTER IX. 

After-ntjrsing of the Different Operations on the Eye. 

Plastic Operations 

Operations where the Eyeball is Opened . . . 
After-care of Operations for Senile Cataract 

Local Complications 

General Complications 



128 
130 
130 
131 
133 
135 
136 
136 
138 
139 



140 
151 
152 
155 
159 



viii CONTENTS. 

CHAPTER X. 
Dressings, Shades, etc. 

page 

Dressings 162 

Antiseptic Dressings 165 

Bandages 166 

Application of Bandages 167 

Special Bandages 172 

Masks and Shields 174 

Redressings 177 

Shades and Protective Glasses 179 

Artificial Eyes 181 

CHAPTER XL 

What to Do in Emergencies. 

Injuries to the Eyes from Caustics and Burns 184 

Contusions and Penetrating Wounds 186 

Infectious Materials in the. Eyes 187 

Poisoning from Atropine, Cocaine and Holocaine _ 187 



Part II. — Nursing of Ear Diseases. 



CHAPTER I. 
Anatomy and Physiology. 

Anatomy of Ear 189 

The External Auditory Canal 189-191 

The External Ear 190 

The Membrana Tympaui 190 

The Middle Ear 192 

The Internal Ear ; 193 

Physiology of the Ear 194 

Collection of Sound Waves 194, 195 

Transmission of Sound Waves 195, 196 

Balancing Power 196 

Ventilation of the Ear 196 

CHAPTER II. 

General Methods of Nursing in Ear Cases. 

The Ear Douche 198 

Method of Douching 198 

Sterilization of Bag 198 

Force of Stream 199 



CONTENTS. ix 

PAGE 

Solutions 199 

Medication . . .*. 199, 200 

Temperature 200 

Preparation of Patient 200 

Unfavorable Results 201 

What is Accomplished 202 

Ear Drops 202 

Temperature 203 

Position of Patient 20.3 

Medication 204 

External Applications 205 

Counter-irritants 205 

Ice Coil 205 

Poultice 206 

Leeches 209 

Method of Using 209 

Dangers of Using 210 

Method of Politzerization 211 

CHAPTER III. 
Preparation for Operation. 

Sterilization of Ear 21.3 

Arrangement of Table) for Treatment of Ear Diseases 215 

Arrangement of Instruments 216 

Preparation of a Living Room for Operation 217 

Illumination 217 

Treatment of the Floor 218 

The Improvised Table 218 

Sterilization of Linen 218 

Sterilization of Dressings 219 

Sterilization of Basins 220 

Sterilization of Instruments 220 

Sterilization of Surgeon 220 

CHAPTER IV. 

Treatment after Operation. 

Recovery from the Anesthetic 221 

Powders 222 

Dressings after Operation on External Ear 223 

Dressing after Paracentesis 223 

Dressing after Mastoid Operation 224 

Sterilization 224 

Irrigation 224 

Packing with Gauze 225 

Frequency of Dressings 226 



x CONTENTS. 

PAGE 

Mastoid bandage 226 

Dressings after Furunculosis 227 

Dressings after Ossiculectomy 227 

Dressings after Application of Leeches 228 

CHAPTER V. 

Ear Nursing in Special Cases. 

Cerumen 229 

Cutaneous Eruptions 230 

Atresia of Auditory Canal 230 

Foreign Bodies 231 

Paracentesis 232 

Chronic Catarrh of the Middle Ear 233 

Structure of the Eustachian Tube 234 

Acute Inflammation of the Middle Ear 234 

Chronic Purulent Inflammation of the Middle Ear 238 

Treatment of Adenoids 240 

Nursing of Deafness after E, ar Discharge has Ceased 241 

Nursing in Mastoid Cases 242 

At Operation 243 

After Operation 244 

Ear Polyps 247 

Acute Hyperemia of Labyrinth 248 



. Part III. — Nursing of Nose and Throat Diseases. 



CHAPTER I. 

Anatomy and Physiology. 

Anatomy of the Nose 249 

The External Nose 249 

The Internal Nose 249 

The Nasal Chamber " 250 

The Turbinates 250 

The Nasal Meatus 250 

The Accessory Sinuses . 252 

Frontal Sinus 252, 

Antrum of High more 252 

Ethmoidal Sinus 253 

Sphenoidal Sinus 253 

Anatomy of the Naso-pharynx 254 

Anatomy of the Pharynx 254 



CONTENTS. x i 

PAGE 

Anatomy of the Larynx 254 

Cartilages 254 

Epiglottis 255 

False and True Cords 255 

The Vestibule 256 

The Sinus of Morgagni 256 

Physiology of the Nose 256 

Secretion 256 

Respiration : 257 

Filtration 257 

Heating 257 

Olfaction 257 

Physiology of the Naso pharynx . 257 

Physiology of the Pharynx 257 

Physiology of the Larynx 257 

CHAPTER II. 
Preparation for Operation. 

Local Anesthesia 259 

Heat 259 

Cold 260 

Phenol-camphor 260 

Carbolic Acid 260 

Eucaine 260 

Novocaine 260 

Cocaine 260 

Methods of Application 260 

Strength of Solutions 261 

Symptoms from Cocaine 261 

Poisoning 262 

Prevention of Poisoning 262 

General Anesthesia 263 

Nitrous oxide 263 

Ether 263 

Chloroform 263 

Dangers from Inspiration of Blood 264 

Stripping the Larynx 264 

Operation with Head over End of Table . 264 

Degree of Anesthesia 264 

Position and Preparation of Instruments and Apparatus .... 264 

Illumination 264 

Sterilization of Instruments 266 

Towels 266 

Vessels and Tray 266 

Sheets and Splints 266 

Hands 267 



xii CONTENTS. 

PAGE 

Use of Wet Towel 267 

Chloride of Lime Method 267 

Permanganate of Potash and Oxalic Acid Method .... 268 

Sterilization of Rubber Gloves 268 

Preparation of the Patient 269 

Removal of Hair 270 

Washing 270 

Shaving 270 

Treatment of Mustache 270 

The Nasal Douche 270 

Temperature 271 

Density 272 

Medication . . .' 272 

Method of Use '. 272 

The Pharynx Douche : . . 274 

Protection of the Hair 275 

Diet 276 

Bowels 276 

CHAPTER III. 

Care of Patient during and after Operation. 

Care of Patient during Operation 277 

Sponges and Pledgets of Cotton 277 

Reception of Pathological Material 277 

Mouth-gag • ' 277 

Care of Eyes 278 

Inspiration of Blood ' 278 

Care of Patient after Operation 278 

Hemorrhage 279 

Detection of Hemorrhage 279 

Treatment of Hemorrhage by Pressure and Ice 280 

Plugging 280 

Hot Water Douche 281 

Peroxide of Hydrogen 281 

Suprarenal Preparations 281 

Complete Plugging 281 

Postnasal Plug 282 

Method of Use - 282 

Reaction . . . 285 

Treatment of Reaction 286 

Disturbance of Parts 287 

Vomiting of Blood 288 

Headache 289 

Stupor • ' [ 289 

Sepsis 289 

Forms 289 



CONTENTS. 



xiii 



PAGE 

Treatment of Sepsis 290 

Of Frontal Sinus -. ... 291 

Of Antrum of Highmore 291 

After Septum Operation 292 

After Adenoid Operation 292 

After Tonsil Operation 293 

After Cleft Palate Operation 294 



CHAPTER IV. 
Diet after Operation. 



Diet after Operations 295 

General 295 

Nose Operations 296 

Cleft Palate Operations 296 

Tonsil and Adenoids 296 

Amputation of Epiglottis 297 

Intubation 298 



Laryngotomy and Laryngectomy 



CHAPTER V. 

Special Therapeutic Measures. 

Special Therapeutic Measures 300 

External Applications 300 

Heat 300 

Cold 300 

Soothing Applications 301 

Counter-irritations 301 

Splints 301 

Dressing after Plastic Operations 302 

Douching of Larynx 303 

Douching of Pharynx 304 

Douching of Nose 304 

Proper and Improper Methods 304 

Dangers 305 

Temperature of Douche 305 

Specific Gravity of Solution 305 

Position of Patient : • • 306 

Respiration while Douching 306 

Blowing and Drying 306 

Postnasal Syringe 30' 

Spraying 3°» 

Internal Applications 

Powders ||* 

Vapor or Steam Inhalations 312 

Fume Inhalations 312 



xiv CONTENTS. 

PAGE 

Nebulizers * 313 

Gargles 314 

Lozenges 315 

Vaccines 315 

CHAPTER VI. 

Nursing Methods in Particular Cases. 

External Diseases of the Nose 316 

Fracture of Nose 316 

Internal Diseases of the Nose 317 

Acute Rhinitis 317 

Diphtheria 317 

Care of Patient 317 

Isolation 317 

Prevention of Contagion 317 

Care of Receptacles 317 

Care of Secretions and Discharges 317 

Care of Bedding 318 

Care of Eating Utensils 318 

Disinfection of Physician 319 

Care of Nose and Throat 319 

Care of Hands 319 

Immunization of Nurses 320 

Duration of Infective Period 320 

Disinfection of Room 321 

Disinfection of Furniture 321 

Sunshine and Fresh Air 322 

Nourishment 322 

Rest in Bed 322 

Croup Kettle 322 

Local Treatment 323 

Calomel Fumigations 323 

Intubation 324 

Antitoxin 327 

Hypertrophic Rhinitisi 328 

Operation on Accessory Nasal Sinuses 328 

Antrum of Highmore 328 

Frontal Sinus 328 

Ethmoid Cells 328 

Tonsil Operation 329 

Peritonsillitis 332 

Edema of " Larynx 332 

Tuberculosis of Larynx 332 

Tumors of Larynx 332 

Operations on the Larynx 333 

Index 336 



ILLTJSTKATIOitS. 



FIG. PAGE 

1. Child's Head in Surgeon's Lap for Cleansing the Eye .... 22 

2. Showing how to Evert the Upper Lid Standing Back of the 

Patient 25 

3. Showing Method of Instilling Drops into the Eye 93 

4. Chalk's Eye-drop Bottle 94 

5. Andrews's Aseptic Eye-drop Bottle 94 

6. Galezowski's Eye-drop Bottle 95 

7. Stroschein's Aseptic Drop Bottle and Stand 96 

8. Glass-Stoppered Aseptic Drop Bottle 97 

9. Showing how to Make Application to the Upper Cul-de-sac. 99 

10. Showing Method of Placing Retractor under the Upper 

Lid 100 

11. Alum Pencil and Holder 102 

12. Combination Hot Air, Hot Water, and Steam Sterilizer. . 134 

13. Oval Eye Patch held on by Strips of Plaster 164 

14. Single Roller Bandage 168 

15. Double Roller Bandage 169 

16. Figure of Eight Bandage for one Eye 170 

17. Figure of Eight Bandage for Both Eyes 171 

18. Moorfields Bandage 172 

1!). Stephenson's Dumb-bell Bandage 173 

20. Ring's Mask 175 

21. McCoy's Shield 176 

22. Andrews's Aluminum Shield 177 

23. Position of Patient with Head Hanging over End of Table. 265 

24. Method of Using a Nasal Douche 271 

25. Nasal Douche 273 

20. Applicators Wound with Cotton 274 

27. Method of Making a Cap from a Towel 275 

28-31. Postnasal Plug 283 

32. Stripping the Trachea and Larynx to Remove Clots of 

Blood or the Intubation Tube, 327 

(xv) 



Eye, Eab, Nose, and Theoat 
Nuesing. 



PAET I -EYE. 



CHAPTER I. 

THE TRAINING AND REQUIREMENTS NECESSARY FOR 
OPHTHALMIC NURSING; A BRIEF SKETCH OF THE 
ANATOMY AND PHYSIOLOGY OF THE EYE. 

Necessary Requirements — Eyebrows — Eyelids — Lacrymal Ap-' 
paratus — Ocular Muscles — Conjunctiva — Cornea — Sclera — Aque- 
ous Humor — Vitreous Humor — Crystalline Lens — Uveal Tract — 
Choroid — Ciliary Body — Iris- — Retina — Optic Nerve — Orbits — Eye- 
ball — Accommodation — Binocular Vision. 

In nursing, as in medicine, a good general training is 
necessary before the special branches, or "specialties," can 
be taken up with advantage. It seems almost unnecessary, 
therefore, to make the statement that a nurse in order to 
become proficient in nursing diseases of the eye should 
first have had a thorough training in the care of general 
diseases. Without this general training she may not hope 
to attain success in special work of any kind. The first 
requirement, then, to become proficient in ophthalmic 
nursing is a thorough grounding in general nursing. This 
may be had in the usual way at the numerous training 
schools for nurses and the hospitals with which they are 

(1)' 



2 



EYE NURSING. 



connected. Of late years some of the training schools have 
had arrangements with special hospitals (eye, ear, nose, 
and throat) by which they could give some of their stu- 
dents training for a few months in these special branches. 
While this arrangement is desirable and an advance over 
the old methods of no training whatever in special 
branches, except an occasional case, it is not adequate for 
present day requirements. 

In order to become a proficient ophthalmic nurse, at 
least twelve months' service in a special ophthalmic hos- 
pital is necessary, while double this length of time in such 
an institution would not be too much time in the majority 
of instances. In such an institution not only is a familiar- 
ity with the appearance of the different affections of the 
eyes obtained, but the proper methods- of handling and 
caring for such diseases are taught; also the preparations 
of the different dressings and bandages for the eyes are 
taught, as well as the preparation of patients for the 
different operations on the eye. 

The art and technique of cleansing an eye, familiar- 
ity with the various instruments used upon the eye, the 
proper after-treatment of operative cases, a knowledge of 
the different remedies used in the treatment of the eye are 
all to be had in these special institutions. It is urged upon 
those who are desirous of becoming proficient ophthalmic 
nurses, therefore, first, to ground themselves in the gen- 
eral training; second, then in the special training in some 
ophthalmic hospital. In fact, this must be the course pur- 
sued by most nurses. Occasionally, without this training, 
a nurse may "pick up" the special nursing on her own 
initiative, or by the advice and assistance of some oculist, 
and become an expert special nurse. This is the exception, 
and such an instance, nowadays at least, is a rare occurrence. 



ANATOMY AND PHYSIOLOGY OF EVE. 3 



A Brief Outline of the Anatomy and 
Physiology of the Eye. 

While the purport of tliis little volume will not allow 
of an extensive review of the anatomy and physiology of 
the eye, yet a very brief exposition of the subject is neces- 
sary for an intelligent understanding of the care and 
nursing of this most delicate organ of the body — the e3 r e. 

eyebrows. 

The eyebrows are two thickened ridges of skin, 
covered with short hairs, arched above the upper borders 
of the orbits. They serve to some extent to protect the 
eyes from light, dirt, and perspiration. 

EYELIDS. 

The eyelids, upper and lower, are two movable cur- 
tains which cover the entrance to the orbit and protect the 
eyeball. The upper lid is larger and more movable than 
the lower lid and has a special muscle, levator palpebral 
superioris, to lift it. 

The lids proper are composed of dense connective tis- 
sues, known as the tarsal cartilage. 

They are attached to the margins of the orbits by 
means of connective tissue membranes — the tarso-orbital 
fasciae. Their free edges are straight and covered with a 
row of hairs, the eyelashes. These lashes serve for protec- 
tion to the eyes. The outer surfaces of the lids are covered 
with delicate skin, loosely attached to the orbicularis 
muscle. The orbicular muscle lies between the skin and 
the tarsal cartilage and serves to close the eye. The inner 
surfaces of the lids are lined with a delicate membrane, 
the conjunctiva. Imbedded in the lids are some small 



4 



EYE NURSING. 



glands, the Meibomian follicles. These glands open on the 
free borders of the lids, and furnish a sebaceous material. 
The opening between the free margins of the eyelids is 
called the palpebral fissure. It is the width of this space, 
larger or smaller, that gives to the eyes the appearance of 
largeness or smallness, and not the actual size of the eye 
itself. The eyes of all adults are nearly of the same size, 
about one inch in all of its diameters. 

The eyelids serve chiefly as a protection to the eyes, 
and by their constant motion the eyeball is kept moist and 
free from dust. 

The arteries to the lids are supplied in the main by 
the ophthalmic artery, while the veins empty into the tem- 
poral and facial veins. The lids are innervated by branches 
from the seventh, fifth, third, and the sympathetic nerves. 
The lymphatics in the lids are numerous. 

LACRYMAL APPARATUS. 

The lacrymal apparatus consists of two portions: a 
secreting — the conjunctiva and lacrymal gland; and a con- 
ducting — the lacrymal canals, the lacrymal sac, and the 
nasal duct. 

The gland, a small almond shaped body, lies in a fossa 
at the upper outer angle of the orbit. About twelve small 
ducts lead from it and carry its secretions to the surface of 
the conjunctiva at the upper outer end of the upper lids. 
This secretion keeps the inner surface of the lids moist. 

At the inner ends of the lids, upper and lower, are two 
small openings, puncta lacrymalia, from which small open- 
ings, the lacrymal canals, lead into the lacrymal sac. 

From the lacrymal sac a small duct ( lacrymo-nasal ) 
leads into the nose, opening on the floor of the same. 
Through these openings the tears drain into the nose. The 



OCULAR MUSCLES. 



5 



tears drain into and through these very small lacrymal 
canals (about 1 millimeter in diameter) by capillary attrac- 
tion, and not by force or gravity. This is a slow process, 
and when the tears are in excess, as in weeping, they run 
over the cheeks because of the inability of the tear-ducts 
to drain them through the nose. The lacrymal gland is 
supplied with blood from the ophthalmic artery, and is in- 
nervated by the fifth and the sympathetic nerves. 

OCULAR MUSCLES. 

Six muscles, four straight recti and two oblique, give 
to the eve its varied motions. They are : the superior rec- 
tus, inferior rectus, internal rectus, external rectus, superior 
oblique, and inferior oblique. They are designated as the 
extrinsic muscles of the eye, while the ciliary muscle and 
the sphincter muscle of the iris are termed the intrinsic 
muscles of the eye. 

The four recti muscles arise immediately around the 
optic foramen, partly from a tendinous ring and partly 
from the optic foramen itself. From this origin they pass 
forward, diverging as they advance until they come in con- 
tact with the eyeball just behind its equator. Keeping in 
contact with it, they pierce its sheath (Tenon's capsule) 
from y s to 1 / 3 inch back of the corneal margin to become 
inserted into the sclerotic coat, by tendinous expansions — 
one above, one below, one to the inner side, and one to the 
outer side of the eyeball. 

The superior oblique muscle arises near the optic fora- 
men, passes forward through a pulley attached to the upper 
inner angle of the orbit, and then is deflected backward be- 
neath the superior rectus muscle to become attached to the 
posterior outer surface of the eyeball. 



6 



EYE NURSING. 



The inferior oblique arises from near the inner anterior 
angle of the orbit, passes outward and backward beneath the 
eyeball, and becomes attached to the posterior outer surface 
of the eyeball. The recti muscles move the eye up and 
down, in and out, while the oblique muscles give to the eye 
a rotary motion. In many, in fact most, of the movements 
of the eye, all of the muscles take part. 

The muscular branches of the ophthalmic artery supply 
blood to the extrinsic muscles of the eye. The venous blood 
is emptied into the ophthalmic and facial veins. 

The sensory nerves are from, the fifth. The motor 
nerves to the muscles are : the third to the internal, supe- 
rior and inferior, recti, and to the inferior oblique, muscles ; 
the fourth to the superior oblique, and the sixth to the ex- 
ternal rectus. 

There are special centers governing the co-ordinate ac- 
tions of the ocular muscles, while their voluntary actions 
are governed by centers situated in the cortex of the brain. 

CONJUNCTIVA. 

The conjunctiva is the mucous membrane lining the 
inner surface of the eyelids and covering the anterior half 
of the eyeball. The epithelial layer of the conjunctiva is 
transparent and extends entirely across the cornea, forming 
the anterior layer of that structure. At the inner corner 
of the eye the conjunctiva forms a crescentic fold, plica 
semilunaris; and resting upon this fold is a small red 
mass of tissue, caruncula lacrymalis. The conjunctiva is 
richly supplied with blood from the branches of the oph- 
thalmic artery, while its nerve supply is derived chiefly 
from the seventh nerve. 

Besides assisting to retain the eyeball in position, the 
chief function of the conjunctiva is to form a smooth cover- 



CORNEA AND SCLERA. 



7 



ing for the inner surfaces of the eyelids and the outer sur- 
face of the anterior half of the eyeball, and by its secretion 
to keep the opposing surfaces moist and lubricated, allowing 
of free movement without friction. 

CORNEA. 

The cornea is a perfectly clear and transparent mem- 
brane forming the anterior one-sixth of the external surface 
of the eye. It is about 1 millimeter in thickness and com- 
posed of five layers, from before backward, as follows : ( 1 ) 
epithelial layer, a continuation of the epithelium from the 
conjunctiva; (2) anterior limiting membrane (Bowman's) ; 
(3) true corneal tissue; (4) posterior limiting membrane; 
(5) endothelial layer. The chief function of the cornea is 
to transmit and refract rays of light entering the eyes 

The nerve supply of the cornea is from the fifth nerve. 
The cornea has no blood-vessels and depends for its nutri- 
tion upon the lymph thrown out from loops of blood-vessels 
near its margins. There are lymph-spaces in the corneal 
tissue for the circulation of this nutritious material. 

SCLEEA. 

The sclera is a dense, white, fibrous membrane which, 
together with the cornea, forms the complete outer tunic 
or coat of the eyeball, the cornea forming the anterior one- 
sixth and the sclera the posterior five-sixths. That portion 
of the sclera seen between the lids when open is commonly 
called the "white" of the eye. Owing to its density and 
firmness it protects the inner and more delicate coats of the 
eye, the choroid and retina. It also maintains the shape 
of the eye, being assisted in this, however, by the vitreous, 
which fills the interior of the eye. 



8 



EYE NURSING. 



The blood-vessels of the sclera are the ciliary arteries 
from the ophthalmic. 

AQUEOUS HUMOR. 

The aqueous humor is a clear, serous fluid filling the 
anterior chamber of the eye. It is composed chiefly of 
water, with a small amount of albumin and chloride of so- 
dium. It is secreted by the blood-vessels of the iris and 
ciliary body, and is quickly reproduced when evacuated by a 
puncture of the cornea. It fills both portions of the ante- 
rior chamber of the eye. The anterior chamber is the space 
between the posterior surface of the cornea and the anterior 
surface of the iris. The posterior part is the space between 
the posterior surface of the iris, near its periphery, and the 
anterior surface of the lens, near its periphery. The 
aqueous humor helps to maintain the shape of the eye and 
allows free movement of the iris. 

VITREOUS HUMOR. 

The vitreous humor is a transparent, gelatinous sub- 
stance filling the interior of the eyeball back of the crystal- 
line lens. It is surrounded by a very delicate, transparent 
membrane. The vitreous has no nerves or blood-vessels. 
It depends for its nutrition upon the lymph thrown out 
from the blood-vessels of the adjacent structures, the uveal 
tract and retina. The chief function of the vitreous body 
is to maintain the shape of the eye, and to keep the con- 
tiguous structures in position ; that is, the retina from 
becoming detached, and the lens from dislocation. 

CRYSTALLINE LENS. 

The crystalline lens is a perfectly transparent lentil- 
shaped body surrounded by a transparent, elastic membrane 



UVEAL TRACT AND CHOROID. 



9 



(its capsule) and held in position just back of the pupil of 
the eye by means of a suspensory ligament, the zone of Zinn. 
It is composed of fibers held together by a delicate, trans- 
parent, cement substance. Water, albuminous material, and 
a small amount of fat, with a trace of cholesterin, enter 
into its composition. In young subjects the lens and cap- 
sule are quite elastic in nature; but, as the subject gets 
older, the lens lopes part of its watery element, the fibers 
become dryer and harder and lose elasticity, and at the age 
of 40 years or thereabouts old sight supervenes, due chiefly 
to a flattening of, and a lack of elasticity in, the crystalline 
lens. The lens, like the vitreous, is without nerves and 
blood-vessels, depending for its nutrition upon the lymph 
thrown out from the blood-vessels of the iris and ciliary 
body. The function of the crystalline lens is to assist in 
bringing rays of light to a focus on the retina. In conse- 
quence of its elasticity and the action of the ciliary muscle 
its refractive power is variable. 

UVEAL TRACT. 

The uveal tract forms the second, or middle, tunic of 
the eve. It is composed of the choroid, ciliary body, and 
the iris. 

CHOROID. 

The choroid is a thin and very vascular membrane, ex- 
tending from the entrance of the optic nerve into the eye, 
forward, between the sclera and retina, to where it joins the 
ciliarv body. It is composed chiefly of blood-vessels. Its 
layers from without inward are: (1) lamina fusca, (2) 
tunica vasculosa, (3) mcmbrana chorio-capillaris, and (4) 
lamina vitrea. 

The structure of the choroid being highly vascular, its 
chief function, together with the ciliary processes, is to sup- 



10 



EYE NURSING. 



ply nutrition to the structures lying adjacent, — the lens, 
vitreous, and outer layers of the retina, — which are de- 
ficient entirely or partially of blood-vessels. The large 
veins in the choroid are called vence voriicosce. They pierce 
the sclera obliquely and empty into the ophthalmic vein. 
The nerve supply is from the fifth and sympathetic nerves. 

CILIAKY BODY. 

The ciliary muscle forms the middle zone of the uveal 
tract, connecting the choroid behind with the iris in front. 
It is composed of the ciliary muscle and the ciliary 

processes. 

The ciliary muscle arises from the sclera just at the 
junction of the cornea and sclera; its outer longitudinal 
fibers extend backward to be inserted into the choroid, while 
its inner fibers take a circular course and form the circular 
fibers of Midler. From the surface of the ciliary processes 
connective tissue fibers spring, forming the zonule of Zinn. 
These fibers are attached to the capsule of the crystalline 
lens, and it is by their aid that the lens is held in position. 

The ciliary muscle is the principal agent in adjusting 
or accommodating the eye to see objects distinctly at differ- 
ent distances. The accommodation of the eye is effected as 
follows : — 

In describing the crystalline lens we said it was elastic, 
and that it was surrounded by a capsule, likewise elastic. 
Attached to the capsule are connective tissue fibers (zonule 
of Zinn) , which are also attached to the ciliary processes and 
ciliary muscle. When the ciliary muscle is not acting these 
zonule fibers are stretched taut and draw on the lens cap- 
sule, which in turn compresses the lens. The lens in this 
way is flattened and the focus of the eye adjusted for dis- 
tant objects. On the other hand, when the eye is to be ac- 



IRIS AND RETINA. 11 

commodated for near objects the ciliary muscle contracts, 
drawing the zonule fibers forward, thus relaxing them ; they 
in turn relax the tension on the capsule of the lens, and 
the lens, being elastic, expands, becoming more convex, and 
in this way the eye is adjusted for seeing near objects. 
During the act of accommodation, in addition to the lens 
becoming more convex, the pupil contracts, the pupillary 
margin of the iris moves slightly forward, being pushed by 
the anterior surface of the lens, which advances a little as it 
becomes more convex. The posterior surface of the lens 
becomes a little more convex, but does not move forward. 

The ciliary processes are very richly supplied with 
blood. A nutritious lymph is thrown out from them which 
nourishes the lens., and the anterior portion of the vitreous. 

IRIS. 

The iris is the third and anterior zone of the uveal 
tract. It is a thin membrane arising from the anterior sur- 
face of the ciliary body. It has a central perforation, the 
pupil. The layers from before backward are : (1) endothe- 
lial layer, (2) vascular layer, (3) muscle-fiber layer, (4) 
posterior limiting membrane, and (5) pigment layer. 

The iris aids in the act of vision by controlling the 
amount of light going into the eye, and by cutting off the 
marginal rays of light. It is supplied with blood from 
branches of the ophthalmic artery. Its nerve supply is 
from the fifth, the third, and sympathetic nerves. 

RETINA. 

The retina forms the inner tunic of the eye, and ex- 
tends from the optic nerve entrance forward to the posterior 
extremity of the ciliary body, where its nerve elements 
end in a serrated border, ora serrata. The pigment layer 



12 



EYE NURSING. 



of the retina, together with its connective tissue elements, 
reduced to a single layer of cells, continues on the inner 
surface of the ciliary body and on to the posterior surface 
of the iris even to the margin of the pupil. In the living 
subject the retina is almost transparent, having a whitish- 
gray, filmy appearance, when viewed by the ophthalmo- 
scope. It is composed of ten layers ; from within outward 
they are: (1) internal limiting membrane, (2) optic- 
nerve fiber layer, (3) ganglion-cell layer, (4) internal 
molecular layer, (5) internal nuclear layer, (6) external 
molecular layer, (7) external nuclear layer, (8) external 
limiting membrane, (9) rods and cones layer, and (10) 
pigment layer. The layer of rods and cones is the per- 
ceptive layer of the retina. Situated in the center of the 
retina in the posterior portion of the eye is a yellow spot, 
macula lulea. At the center of this spot is a depression, 
fovea centralis, which is the center of direct vision and is 
the most sensitive portion of the retina. The retina is 
supplied with blood by the arteria centralis retince, a branch 
from the ophthalmic which pierces the optic nerve just 
back of its entrance into the eyeball. The branches from 
this artery- lie in the outer layers of the retina, and ter- 
minate in free endings, no anastomoses taking place. The 
retinal veins empty into the ophthalmic vein. 

OPTIC NERVES. 

The optic nerves are nerves of a special sense, that of 
sight. They have their origin in the brain as the optic 
tracts which emerge from its under-surface at the posterior 
portion of the optic thalami by two roots. Fibers from 
these roots extend to the cortex of the occipital lobe of the 
brain, where the visual center of the brain is situated. The 
optic tracts decussate anteriorly ; that is, about three-fifths 



ORBITS. 



13 



of the fibers from the right tract cross over to the left optic 
nerve and three-fifths of the fibers of the left tract go over 
to the right optic nerve. This crossing of the optic tract 
fibers forms the optic chiasm. The length of the optic 
nerves from their origin in the optic chiasm to the eyeball 
is about 1 inch. The optic nerves are surrounded by sheaths 
which are direct continuations of the membranes surround- 
ing the brain. The spot where the optic nerve enters the 
eve is known as the optic disc. The blood supply to the 
optic nerve, chiasm, and optic tracts is derived chiefly from 
the branches of the internal carotid and vertebral arteries. 
The function of the optic nerve and tracts is to transmit 
visual impressions to the brain. The conscious preception 
of the visual impressions gives sight. 

ORBITS. 

The orbits are the bony cavities in which the eyeballs 
are contained and by which they are protected. They are 
funnel shaped ; the large end of the funnel is directed 
forward and the small end backward, terminating in the 
optic foramen through which the optic nerve enters the 
orbit and also the ophthalmic artery. Near the posterior 
end of the orbit is another opening, the sphenoidal fissure, 
through which pass the third, fourth, ophthalmic division 
of the fifth and sixth nerves, and the ophthalmic vein. The 
bony orbit is lined by a layer of dense connective tissue; 
fibers spring from this connective tissue which expand into 
sheaths. One of these sheaths surrounds the optic nerve 
and the eyeball, except the front portion, and in this cap- 
sule the eyeball tarns as in a ball-and-socket joint. The 
posterior part of this membrane is called Bonnetf s capsule, 
and the anterior portion Tenon's capsule. At the apex of 
the orbit is a cushion of fat, which supports the eyeball. In 



14 



EYE NURSING. 



wasting diseases, as consumption, when this fat is absorbed 
the eyes become sunken or hollow from lack of support. 

eyeball; accommodation; binocular vision. 

The function of the orbits is to furnish protection to 
the eyeballs. The eye as a whole may be likened to a cam- 
era. At the front surface are the cornea and lens to focus 
the rays of light; and the iris with its central perforation, 
the pupil, which can be changed in size, to regulate the 
amount of the light; while the retina at the back of the 
eye is the sensitive plate upon which the images are re- 
ceived. As this plate cannot be moved backward and for- 
ward, as in a camera, the ciliary muscle is brought into use 
in order to have clear images of objects at varying dis- 
tances formed on it. By the action of this muscle and the 
elasticity of the crystalline lens itself the lens can be made 
to change its convexity. In this way the images of objects 
at different distances can be accurately focussed on the 
retina, and this is the act of accommodation. The impres- 
sions of these images are transmitted to the sight-perceptive 
center of the brain by means of the optic nerves and tracts. 
The images of all objects fall on the retina in an inverted 
position; that is, upside down; nevertheless they are in- 
terpreted by the brain as being erect, or upright. More- 
over, the images of an object formed in each eye separately 
are fused into one which is seen singly. When the two eyes 
are not directed straight to an object, but one deviates so 
that the image of the object does not fall directly on the 
center of the retina, the macula lutea, double vision follows, 
as a rule. Just how the brain is able to perceive these in- 
verted images on the retina as erect and single we are 
unable to understand, and it has resulted in much discus- 
sion and speculation. 



CHAPTER II. 



CONTAGIOUS DISEASES OF THE EYE. 

Definition of Contagion and Infection — Epidemic and En- 
demic — Germ Theory of Disease — Definition of Antisepsis and 
Asepsis — Catarrhal Conjunctivitis — Gonorrheal Conjunctivitis — 
Ophthalmia Neonatorum. 

By contagious diseases of the eye we mean those dis- 
eases which can be transmitted either directly or indirectly 
from one eye to another. In all contagious diseases of the 
eye there is more or less discharge from the eye, and it 
is by some of this matter from the diseased eye to a healthy 
eye — from one eye to the other in the same person or to 
another individual — that the disease becomes communicable 
or contagious. 

In this matter are micro-organisms or bacteria, each 
disease having a germ peculiar to itself, as has been demon- 
strated in recent years in many diseases by means of the 
microscope. When a small amount of this pus is trans- 
ferred from a diseased eye to a healthy one, it usually pro- 
duces a similar disease in the healthy eye. 

In all of the contagious diseases of the eye, except one, 
trachoma, a specific germ has been found to be present 
peculiar to each disease. In trachoma no specific germ or 
microbe has been settled upon as a definite cause of the 
disease, although two or three observers (Michel, Sattler) 
claim a specific germ (a diplococcus) for its origin. 

Before the germ theory of disease was advanced it was 
difficult to explain just how a contagious disease was trans- 
ferred from one individual to another, but, since the dis- 
covery that each contagious disease has a specific germ 

(15) 



16 



EYE NURSING. 



causing it, it is easy to perceive in what manner such dis- 
eases are transferred and how produced. 

The contagious diseases of the eye are : catarrhal con- 
junctivitis, or "pink eye"; gonorrheal ophthalmia; oph- 
thalmia neonatorum; diphtheritic ophthalmia; trachoma, 
or granulated eyelids. Of these diseases the first four are 
highly contagious, the smallest particle of secretion from an 
eye affected with any one of them when transferred to a 
healthy eye being sufficient to produce a similar disease in 
the latter. Usually in these diseases, when the second eye 
becomes affected in the same individual, the disease runs a 
milder course than in the first eye to become affected. 

Trachoma is only mildly contagious, and usually an 
eye has to be exposed to the contagion time and again be- 
fore it becomes affected. When once contracted, however, 
the disease is difficult to get rid of. 

By a few authorities these contagious diseases are 
thought to be infectious; that is, transmitted through the 
air. While it is possible to conceive of particles of the 
matter from eyes affected with these diseases becoming 
dried and then wafted through the air into health}*- eyes 
and setting up a like disease, it is not at all probable. 
The danger from such source of infection is hardly worth 
while considering. For, as shown by the experiments of 
Piringer, these secretions, when dried, after thirty-six hours' 
time became inert and incapable of infecting healthy eyes. 
These diseases are highly contagious ; that is, communicable 
when the pus from a diseased eye is brought in contact with 
a healthy eye! by means of unclean fingers, handkerchiefs, 
towels, etc. ; but they are slightly if at all infectious 
through the air, as measles, mumps, etc. Actual contact 
of the germ, direct or indirect, is a necessary factor in the 
production of these diseases. The extreme importance of 



AXTISEL'SIS. 



17 



absolute cleanliness en the part of the doctor, nurse, 
attendants, and the patient himself in such diseases is self- 
evident. Through uncleanliness and negligence these con= 
tagious diseases may become epidemic ; that k, spread 
through a whole community temporarily. As, for example, 
through dirty public baths a great number of people may 
become afflicted with acute catarrhal conjunctivitis. In 
some instances these diseases are thought to become en- 
demic; that is, permanently fixed in certain localities. In 
Egypt, for instance, trachoma has been endemic for ages; 
and in the southern portion of the State of Illinois on the 
Wabash River in a small district, aptly enough called "Lit- 
tle Egypt.*' the disease is quite prevalent and always pres- 
ent; hence endemic. 

Having considered the causes of contagious diseases of 
the eye, it behooves us to say a few words here in reference 
to antisepsis and asepsis, a subject which will be treated 
more fully farther on. The word antisepsis means literally 
opposed to putrefaction or fermentation. Since micro-or- 
ganisms are at the seat of putrefaction and are the cause, as 
we know, of many diseases, any method or means to destroy 
these germs is termed antisepsis. Heat, dry or moist, 
where it can be applied, as in sterilizing instruments, is an 
effective antiseptic. Carbolic acid, bichloride of mercury, 
alcohol, permanganate of potassium, etc., are common anti- 
septics with which we are familiar. They are antiseptic by 
Teason of their power to kill germs, and are on this account 
also called germicides. Nitrate of silver, argyrol, and pro- 
targol are valuable germicides and they are frequently em- 
ployed in the treatment of the acute contagious diseases of 
the eye. 

Asepsis means literally the absence of putrefaction or 
fermentation, and also the micro-organisms upon which 

2 



18 



EYE NURSING. 



they depend. Hence any method or means used to keep a 
wound free from germs, as by sterile solutions, dressings, 
etc., is termed asepsis. 

In diseases of the eye strong antiseptic solutions can- 
not be used, the eye being such a delicate and sensitive or- 
gan. The solutions of carbolic acid and bichloride of mer- 
cury should not be of greater strength than 1 to 5000. In 
this strength they are only weakly germicidal. If used in 
stronger solution they are very irritating to the eye and 
many times do actual harm. For this very reason in dis- 
eases of the eye, even in the contagious diseases, we depend 
on aseptic methods more than antiseptic means. That is, 
we endeavor to keep the eye clean by frequent bathing 
with aseptic or sterilized solutions, or mildly antiseptic 
solutions. In cases of wounds and after operations we pro- 
tect the eye with sterilized dressings, thus keeping the 
germs out. The old adage, ''an ounce of prevention is worth 
more than a pound of cure," is quite applicable in the treat- 
ment of diseases of the eye, for it is much easier to keep 
these germs out than get them out when once in. This 
point cannot be too strongly impressed upon the nurse's 
mind, for an eye once infected, especially after operation, 
often means the loss of it. 

Acute Catarrhal Conjunctivitis. 

This is an acute contagious disease of the eye, many 
times appearing in epidemic form. It is caused by a micro- 
organism, the Koch-Weeks bacillus. Atmospheric condi- 
tions evidently have some influence in its production, the 
damp, chilly days of spring seeming to predispose to it. 
The disease is characterized in the beginning with redness, 
burning, and itching of the eyes, tfie lids are swollen and 



ACUTE CATARRHAL CONJUNCTIVITIS. 



19 



red, and light hurts the eyes. After a few days' duration 
there is marked increased secretion of a muco-purulent 
nature, which sticks the eyelids together in the morning. 
In one or two weeks, according to the severity of the case, 
the disease runs its course and the patient is well, if the eye 
has been properly taken care of. As a rule, the medicinal 
treatment in such cases is very simple, and consists, for the 
most part, in the application of silver nitrate, 2 per cent, 
solution (10 grains to 1 ounce), to the lids once a day, or 
some other mildly antiseptic application according to the 
bent of the surgeon. Personally I prefer the silver nitrate 
application to all other remedies in this affection. The 
patient may use a 2d per cent, solution of argyrol at home. 

The care and nursing of these cases is important, not 
only in knowing what to do with them, but what not to do. 
Sometimes we need to be delivered from our friends, and if 
there is one disease of the eyes more than another in which 
patients need to be delivered from "grandmother" reme- 
dies and quack nostrums it is this disease. The diagnosis 
given in such cases by these ignorant, dangerous, and free 
givers of advice is that of a "cold in the eyes," which may 
mean anything from a cinder on the cornea to the most 
virulent cases of diphtheritic conjunctivitis. 

The treatment recommended by these sometimes inno- 
cent, but always ignorant and presumptuous, practitioners 
of the healing art, to be applied to the most delicate organ 
of the human body, the eye, may be anything from bathing 
the eyes in breast-milk, the application of poultices, of tea- 
leaves, bread and milk, flaxseed, etc., raw meat, oysters, skin 
of egg, cow dung, a piece of the placenta of a parturient 
woman, and even to bathing the eyes in the patient's own 
urine, from which last practice more than one eye has been 
infected with gonorrheal ophthalmia and the sight de- 



20 



EYE NURSING. 



stroyed. It seems hardly necessary for me to warn any 
intelligent person from carrying out such practices as the 
above mentioned, yet there are so-called intelligent people, 
and not a few of them apparently, who do practice them. A 
campaign of education is in order, therefore, and I know 
of no better time, place, or opportunity than now to start it. 

If called upon to write or formulate the two most im- 
portant precepts in ophthalmic nursing I should do so as 
follows : — 

1. Thou shalt be altogether clean and gentle when 
caring for the eyes. 

2. Thou shalt not apply poultices to the eye. 

I wish that these two short precepts might be indelibly 
impressed on the mind of every nurse and grandmother, or 
other person presuming to nurse, to the end that the sight 
of many eyes might be saved. 

Since Pasteur's discovery that fermentation and putre- 
faction are due to the presence of certain micro-organisms, 
or "germs," we have learned that most, if not all, contagious 
diseases (as well as many non-contagious diseases) are 
caused by germs and their toxins (their poisonous excre- 
tions) . We know also that it is necessary to get rid of these 
micro-organisms before we are truly clean. The methods of 
getting rid of these germs, as by the use of heat, germicidal 
solutions, etc., are termed antisepsis, and were first intro- 
duced by Lord Lister. The means used to keep free of 
these germs, as by soap and water, dressings, etc., are 
termed asepsis. For full particulars in antisepsis and 
asepsis see Chapter V. 

That poultices should never be applied to an eye af- 
fected with a contagious disease is self-evident to the sur- 
gical mind, and for two reasons; first, they retain the 
irritating secretion in the eye ; secondly, they often strip 



ACUTE CATARRHAL CONJUNCTIVITIS. 



21 



the delicate epithelium from the cornea and conjunctiva, 
leaving ulcerating surfaces open to the contagion, and not 
infrequently in this way causing the loss of the eye. The 
use of poultices, therefore, should never be resorted to in 
contagious diseases of the eye. They are dirty, dangerous, 
and altogether an abomination, as well as destructive to the 
sight of man. If heat and moisture must be applied to the 
eye, let it be in the form of hot water, with which the eves 
may be bathed frequently ; or applied by means of pledgets 
of cotton or old, soft, clean linen, dipped into the water 
and laid upon the closed eyes. 

In the mild cases of catarrhal conjunctivitis the pa- 
tient himself is usually able to care for his own eyes, but 
in the severer types, where the secretion is very abundant 
and accompanied at times with ulcers of the cornea and 
exceptionally with membranes on the lids and even with an 
iritis, the services of a nurse are called for. In any case 
the eyes should be cleansed with a warm (98° to 100° F.) 
sterilized solution sufficiently often to keep them free of 
the secretion. A teaspoonful of boracic acid or of table salt 
to the pint of water, and plain sterile water (made so by 
boiling then cooled), are good for cleansing with. This 
should be done every half-hour, if necessary, and is the 
most important factor in the treatment of the disease. The 
technique of cleansing an acutely inflamed and sensitive eye 
is not so simple a matter as it seems. The "touch" of some 
nurses, also of some doctors, in manipulating these cases, is 
as the tread of an elephant. So patients sometimes think 
and say. There is a certain aptness or deftness in the art 
of cleansing an eye gently and well that can be acquired 
only by the exercise of close attention and much patience. 
This deftness is natural to some and is never acquired by 
others. 



22 



EYE NURSING. 



DIRECTIONS FOR CLEANSING AN EYE. 



The nurse herself should have surgically clean hands, 
wear a pair of protective glasses (if she does not already 
wear glasses), and on her lap have a rubber apron. All 
solutions, cotton, cotton applicators, pus basins, etc., should 
be prepared and placed on a small table near a window or 
other source of light convenient to the nurse. If the pa- 
tient is a child, it should be wrapped in a sheet with the 



Fig. 1. — Child's Head in Surgeon's Lap for Cleansing the Eye. 

arms at its side, to prevent the child from interfering with 
the cleansing. 

Over the sheet and well up under the chin a towel 
should be placed for protection to the patient. The child 
is held in the lap of an attendant and with its back to the 
nurse who pulls the child's head backward and places it be- 
tween her knees, as shown in Fig. 1. With the head firmly 
fixed between the knees the lower lid is gently pulled down 
by placing the thumb on the cheek just berfeath the eye, 
exposing the inner surface of the eyelid and the lower cul- 
de-sac (the deep fold of conjunctiva joining the lid to the 




DIRECTIONS FOR CLEANSING AN EYE. 23 

eyeball). Then a stream of water squeezed from a pledget 
of cotton held in the free hand is directed on to the inner 
surface of the lid. This maneuver is repeated until all the 
loose pus is washed away. If any pus remains sticking to 
the lids or eyelashes, this may be gently wiped away with 
the moistened cotton. To cleanse the upper lid and cul-de- 
sac it is necessary to catch the eyelashes of the upper lid be- 
tween the thumb and forefinger of one hand, and pull the 
eyelid forward and away from the eye ; pressure downward 
is then made at the upper edge of the cartilage,- when, as 
a rule, the lid is everted and its inner surface and upper 
cul-de-sac are exposed to view. Then direct a stream of 
water squeezed from a pledget of cotton into the groove 
between the lid and eyeball and on to the lid surface, re- 
peated often enough to wash away the pus. If much pus 
should remain in the cul-de-sac, it may be wiped away by 
means of a moistened piece of cotton on an applicator. If 
the eyelids are so swollen that they cannot be lifted from 
the eye, it is much better that the surgeon perform a can- 
thotomy (cutting the lids at the outer corner of the eye 
with a scissors), when the eyes can be readily cleansed after 
the manner just described. 

All rubber bulbs with narrow tips on them for inser- 
tion under the lids to irrigate the cul-de-sac should, in my 
opinion, be abandoned as dangerous. In using them, espe- 
cially in young children, we are apt to injure the cornea. 
With the simple cotton pledgets we are much less apt to 
do harm to the eye. If it becomes necessary to perform a 
. canthotomy, no harm is done, but rather advantages gained, 
as follows : Pressure of the lids is taken from the eyeball, 
and the risk of ulceration of the cornea is less liable; the 
eyes can be cleansed more easily than before ; local blood- 
• letting is accomplished, which relieves the .congested and 



24 



eye Nursing. 



inflamed eye. The wound from such operation heals in 
about one week's time and leaves no scar. 

The fewer the instruments the less the danger to the 
patient, is a good surgical maxim, and it is especially ap- 
plicable to the eye. 

The second step in caring for a case of catarrhal con- 
junctivitis is the application of iced cloths or cold com- 
presses. Have by the side of the patient's bed a large bowl 
or dish in which place a cake of ice the size of a man's head. 
On this cake of ice place a half-dozen pledgets of old, soft, 
white linen or cotton about 2 inches square; or, better still, 
pledgets of absorbent cotton, moistened; allow them to 
remain on the ice till cold (ten minutes) ; then take one, 
or two, if both eyes are affected, and lay them on the closed 
eyelids. After two minutes take these pledgets off the eye. 
and place them back on the ice, then place two fresh 
pledgets on the eye. Keep changing the pledgets in this 
manner every two minutes for half an hour. This should 
* be repeated four, five, or six times during the day, and, if 
the blennorrhea is very marked, even oftener. 

If ice is not to be had, these pledgets of cotton or cloth 
may be dipped in cold water and applied in the manner 
above indicated. The practice of putting cracked ice into 
a little rubber bag or wrapped in a towel or other cloth and 
laying the same on the eye is a bad one, for the reason that 
it puts too much weight and pressure on the sensitive eye. 
It often does harm rather than good. 

Cleansing the eyes and applying cold compresses are 
the two most important duties of a nurse in such case*. 
The physician in charge usually makes the necessary medic- 
inal applications. 

The most valuable remedy in these cases, at least it has 
been in my hands, is an application to the everted lids 



DIRECTIONS FOR CLEANSING AN EYE. 



25 



of a solution of silver nitrate, 10 grains to the ounce. The 
application is made as follows : — 

If the patient is a child the head is held between the 
knees as in cleansing the eye; after cleansing the eye, the 
lower lid is pulled down by placing the thumb on the cheek 




Fig. 2— Showing how to Evert the Upper Lid Standing 
Back of the Patient. 

at the lower part of the lid. Then an applicator with a 
small amount of cotton wrapped smoothly on it and satu- 
rated with the silver solution is rubbed gently over the 
inner surface of the lid and deep into the lower cul-de-sac. 
The lid is then let loose to come back into position. Next. 
the lashes of the upper lid are caught between the thumb 
and forefinger and the lid pulled gently forward away from 



26 



EYE NURSING. 



the eye; then pressure is made with the blunt end of the 
applicator or the tip of the finger at the upper edge of the 
cartilage (see Fig. 2) and the lid everted. The silver solu- 
tion is then applied to the exposed surface and cul-de-sac. 

It takes a certain amount of deftness to evert the 
upper eyelid gently and without pain, especially when it 
is swollen. It should be practised frequently on the healthy 
eye before undertaken on the diseased organ. The ever- 
sion of an eyelid seems like a matter of exceedingly small 
importance to the surgeon and the nurse, but it is not so 
considered by a sensitive patient. I have known of more 
than one instance where the nurse lost charge of the case 
because she could not turn an eyelid properly. The essen- 
tial point in the technique is first to pull the lid well away 
from the eyeball, then make the pressure at the upper mar- 
gin of the cartilage downward and rather quickly. 

There is one other matter which should be spoken of 
here and that is the art of wrapping cotton on an applicator 
quickly, smoothly, and so that it will stick; also that it 
can be taken off when through with. Take a piece of cotton 
% inch wide, 1 or 2 inches long, and Y 16 (approximately) 
inch thick ; catch one end of it between the thumb and fore- 
finger of one hand, place the extreme tip of the applicator 
on the cotton held between the thumb and finger, hold it 
firmly with the thumb and finger, then twist the applicator 
with the other hand (and not the cotton as is so often done), 
and the cotton will at once adhere to the tip of the ap- 
plicator. The tip should be covered completely first and 
to the depth desired, then the applicator should be pushed 
through the finger and thumb as it is turned so as to cover 
about from 1 to 1*4 inches of the applicator. At the 
upper end only, that is, nearest the handle of the applicator, 
the cotton should be wound very tightly, the edge of the 



GONORRHEAL CONJUNCTIVITIS. 



27 



thumbnail being held against it for this purpose while the 
applicator is turned. This prevents the cotton from com- 
ing off when in use. When ready to take it off, hold the 
cotton firmly between the thumb and finger of one hand, 
and a slight reverse twist of the applicator is all that is 
necessary. 

Camel-hair brushes should not be used for making 
applications to the eyelids, because, unless disinfected after 
use on each patient, they are liable to carry infection. Cot- 
ton placed on an applicator as just described is much prefer- 
able, for this is used, but once and is then destroyed. 

The "eye sponge" has been displaced by cotton, and the 
camel-hair brush is doomed to a like fate. 

The hygienic surroundings of the" patient when af- 
fected with catarrhal conjunctivitis of the severer types is 
of importance. 

The room should be kept moderately darkened for these 
patients ; the diet should be light, but nutritious ; the bow- 
els "kept freely open, and no smoking or stimulants allowed. 
The floor, which should be uncarpeted, should not be swept, 
but mopped up, and all dressings immediately destroyed 
after use. It seems almost unnecessary to warn the nurse 
that she should be very careful with her own person, wash- 
ing and disinfecting her hands often, and never nibbing or 
touching her own eyes. A solution of bichloride of mercury 
(1 to 1000) in a basin should always be near to dip her 
hands into after washing them with tincture of green soap. 

Gonorrheal Conjunctivitis. 
The safety of an eye when affected with this frightful 
malady, causing as it does in adults and infants about one- 
fourth of all ca'es of blindness, depends more on the intel- 
ligent and faithful care of a trained nurse than the minis- 



28 



EYE NURSING. 



trations of a doctor. The disease is caused by infection 
with the germ or the micro-organism of gonorrhea, the 
gonococcus, discovered by Neisser. The disease may affect 
adults or infants; in the former, it is usually designated 
gonorrheal ophthalmia, and in the latter ophthalmia neo- 
natorum. The two diseases are identical. The eyes of chil- 
dren, however, seem to withstand the disease better than the 
eyes of adults. In infants, when seen early (within the first 
twenty-four to forty-eight hours after infection) and be- 
fore the corneae are affected, the eyes are almost always 
saved with useful vision ; but in adults, even when seen from 
the start, no promise can be given to the patient as to re- 
covery with sight preserved. 

In adults, the disease for the first two or three days is 
characterized by redness and by marked swelling of the 
eyelids and conjunctiva, being so great in severe cases that 
the patient cannot open the eyes. The conjunctiva, both 
of the eyelid (palpebral) and the eyeball (ocular), is hot, 
dry, and swollen, and the ocular conjunctiva may become so 
swollen and edematous as to form a ridge around the cor- 
nea, termed chemosds of the conjunctiva. There is intense 
pain in the eyes and over the orbits. This condition lasts 
for from two to four days, when the lids become softer and 
less swollen, and a purulent secretion flows from between 
them. This purulent stage of the disease lasts for from one 
to two or three weeks. 

Ulceration of the cornea may, and often does, take 
place, sometimes with loss of the sight. Inflammation of 
the entire eyeball and orbital contents (panophthalmitis) 
may supervene, with total loss of the eye. 

The nurse's first duty when called to take charge of a 
case of gonorrheal ophthalmia is to protect the unaffected 
eye, if but one is infected. This may be done in one of two 



GONORRHEAL CONJUNCTIVITIS. 



29 



ways: by Buller's protective shield or by bandaging the 
eye. 

B idler's shield is applied as follows: — 
Take an ordinary watch-crystal, which is about 1% 
inches in diameter, and two pieces of adhesive plaster, 
one- of which should be 2 inches square and the other 2% 
inches square; cut a hole 1 inch in diameter out of the 
center of each piece of plaster, paste the smaller piece to 
the concave (hollow) side of the watch-crystal and the 
larger piece to the convex (elevated) surface of the watch 
crystal. 

The outside piece of plaster (which is on the convex 
surface of the crystal), being larger than the inside piece, 
leaves a half-inch margin of the adhesive plaster free. The 
* watch-crystal, concave surface inward, is now placed over 
the unaffected eye and the free margin of adhesive plaster 
fastened to the face, above the eye, on the -nose and below 
the eye, the edges of the plaster being covered with flexible 
collodion to hold them more securely. The temporal side 
is not pasted to the face, but left free to give ventilation 
to the eye. There is but little danger of infection, by hav- 
ing the temporal side open; and, if pasted down, moisture 
from the eye forms a mist on the glass crystal and prevents 
the patient from seeing with the eye, as well as preventing 
a view of the patients eye by the physician. 

In infants and very restless patients, it is better to 
cover the well eye with a pad of gauze and a roller bandage, 
which is not so easily pulled off. (For method of applying 
a protective bandage, see Chapter X.) This bandage 
should be removed twice every day, the eye washed, and then 
the bandage reapplied. 

Cleansing the affected eye, or eyes, as the case may be, 
is the next most important and urgent duty of the nurse. 



30 



EYE NURSING. 



For the first day or two after the inception of the dis- 
ease there is, as a rule, but scanty secretion; but after the 
third or fourth day the secretion from the eyes is copious. 
This pus should not be allowed to remain in contact with 
the eye, as it becomes a source of irritation to the eyeballs, 
and may cause ulceration of the cornea, a complication we 
wish to avoid if possible. In very severe cases, where the 
pus collects quickly, it should be removed every twenty to 
thirty minutes, and in less severe cases every half-hour to 
one hour. The frequency with which an eye should be 
cleansed will depend upon the judgment of the doctor and 
the observation of the nurse. Pus should not remain in 
contact with the eye, and when enough is collected between 
the lids to be noticeable to the attendant it should be re- 
moved at once. A day nurse and a night nurse are neces- * 
sary in such cases ; at night the cleansing should not be as 
frequent as in the day, — perhaps about one-half as fre- 
quently. This is to allow the patient an opportunity to 
sleep. Tf the patient is kept awake too much, his general 
condition is weakened, and this in itself affects the eye in a 
bad way, and may hasten a breaking down or ulceration of 
the cornea. 

If the lids are so swollen that the eyes cannot be readily 
cleansed, a cjanthotomy (cutting of the outer angle of the 
lids) should be performed by the surgeon. As remarked 
above, this not only allows the eyes to be cleansed easily, 
but takes pressure off of the eyeball, and in this way lessens 
the danger of ulceration of the cornea. And it must ever 
be borne in mind that this is a complication we wish most 
ardently to avoid. In cleansing the eye the nurse should 
be very careful not to rub the cornea so as to abrade it, for 
this leaves an open spot for infection and is almost certain 
to result in an ulcer. 



GONORRHEAL CONJUNCTIVITIS. 



31 



When ulceration does take place, it should be reported 
at once to the surgeon, if not already observed by him, be- 
cause it necessitates the instillation of atropine, at once, and 
usually a change from cold to hot applications. 

The application of cold compresses is another impor- 
tant feature of the treatment in gonorrheal ophthalmia, 
and the nurse should be prepared and know how to make 
such application, which may be done in two or three ways, 
as already described when treating of catarrhal conjunc- 
tivitis (see page 24). Iced cloths should not be applied 
too frequently nor too long at a time, because they have a 
depressing effect on the circulation and nutrition of the 
eye. The circulation of the blood in the loops of blood- 
vessels at the periphery of the cornea is already much em- 
barrassed by the chemosis of the ocular conjunctiva, often 
present in the severer cases, and the cold further depresses 
this circulation. While, therefore, the cold compresses re- 
lieve the pain, they should not be used too freely, but only 
just enough to keep down the pain and to help reduce the 
swelling of the eyelids. The cold compresses are of much 
service in the beginning of the disease and should be used 
for 15 minutes in each hour; but after the secretion has 
fully started, and in the later stages of the disease, they 
should be used less frequently. In fact, after the first few 
days cold applications should not be used, neither hot, un- 
less there is ulceration of the cornea. If ulceration of the 
cornea takes place, they should be stopped at once and hot 
applications used in their place. 

Hot applications are applied in the following man- 
ner : Have by the bedside of the patient an open metal ves- 
sel which will hold a quart to half a gallon of water. Fill 
with water and place on a metal stand so that an alcohol 
lamp can be placed beneath. The temperature of the water 



32 



EYE NURSING. 



should be raised to 110° F. Then pledgets of cotton or old 
linen are dipped into this, wrung out, and placed on the eye. 
These pledgets should be changed every minute or two, for 
30 minutes; then rest 30 minutes, or an hour, as the case 
may demand, when they should be repeated. This should be 
done several times a day according to the directions of the 
surgeon. 

If an alcohol lamp is not convenient, hot water may be 
taken frequently in a pitcher from a pot or kettle on the 
stove, and the pledgets of cotton dipped in this and placed 
on the eye. The objection to this method is that the water 
soon cools in the pitcher and, is of variable temperature, 
while the alcohol flame keeps a constant temperature. 

The application of remedies to the lids in these cases 
is usually made by the surgeon or his assistant in charge, 
but often the nurse is called upon to make them, especially 
the instillations of drops and lotions. 

In the very early stages of the disease we may modify 
it (and some surgeons claim to abort it) by applying to the 
everted lids and down deep within the cul-de-sac a strong 
solution of silver nitrate. Buller, of Montreal, advised an 
8 to 10 per cent, solution, which in my opinion is entirely 
too strong, and on no account should a solution stronger 
than 4 per cent, be used, and this should be neutralized im- 
mediately with normal salt solution. Usually not more 
than two such applications are made, and these one day 
apart. 

When the profuse purulent discharge sets in, about the 
third to fourth day, a 2 per cent, solution of silver nitrate 
may be applied to the lids once a day with cotton on an 
applicator, provided the lids can be everted. But often the 
lids are so swollen they cannot be everted, when a can- 
thotomy must be performed, if this line of treatment is to 



GONORB 1 1 EAL ( < >NJ UNCTIVITIS. 



33 



be pursued. In late years the newer preparations of silver 
have come into wide use in these cases — argyrol and pro- 
targol, among others, being used to the exclusion of silver 
nitrate altogether — these preparations have the great ad- 
vantages of: — (1) being non-irritating or but mildly so; 
(2) that they can be used by the nurse and freely without 
damage to the eye ; (3) that it is not necessary to make a 
canthotomy in order to instill the remedy; (4) in that the 
cornea is not so likely to he injured by instilling drops as 
by an applicator with cotton, by which method silver nitrate 
is usually applied. Of all the newer- remedies I prefer 
argyrol and use it in 25 per cent, solution, having the nurse 
cleanse the eye every hour during the day, and at night, in 
order that the patient may get some sleep and rest, the eye 
is cleansed every two hours and the argyrol instilled after 
each cleansing. 

In late years I have ceased to use cold compresses in 
these cases, except for the first two or three days; and no 
hot compresses at all unless an ulceration of the cornea 
occurs, in which case they are applied several times a day, 
following cleansing of the eye. 

All dressings, cotton, linen, etc., used in connection 
with these cases of gonorrheal ophthalmia should be burned 
immediately after use. The nurse herself cannot be too 
careful with her own eyes, always washing her hands each 
time after cleansing or touching the eyes of the patient, 
and then dipping the hands into a strong solution of 
bichloride of mercury (1 to 1000). That the danger of 
infection of the nurse's eyes and also of the eyes of the 
family and friends of patients affected with gonorrheal 
ophthalmia is not an imaginary one, may be inferred 
from the following quotation from Professor Fuchs, 
of Vienna : — 

3 



34 



EYE NURSING. 



"In the Vienna Foundling Asylum, during the years 
1812 and 1813, there were for every hundred infants af- 
fected with blennorrhea (ophthalmia neonatorum) more 
than fifteen nurses so affected, who had acquired their eye- 
disease from the infants. I have seen a whole family in- 
fected with blennorrhea by a child having blennorrhea neo- 
natorum, and thus plunged into the greatest misery." 
("Text-book of Ophthalmology," page 54.) 

I myself have seen more than one nurse's eyes infected 
with gonorrheal ophthalmia contracted from the eyes of 
the patient whom she was nursing. Too much stress, 
therefore, cannot be laid upon this matter of prevention of 
infection of the attendants and the neighbors of; the pa- 
tient afflicted with this highly contagious disease. Abso- 
lute cleanliness on the part of the nurse, protective glasses 
for her eyes, burning of all dressings, cotton, etc., used in 
cleansing the eyes, should be strictly followed out. 

The room or ward in which such patients are cared for 
should have but little furnishing, and that plain, with no 
carpet on the floor ; and should be well ventilated and mod- 
erately well lighted. 

The general condition of the patient should be care- 
fully attended to. Plenty of nutritious, fluid diet, and 
tonics, if necessary, should be given. All company should 
be excluded, both for the comfort of the patient and the 
prevention of possible infection of the visitor. The room 
in which such cases have been taken care of should be thor- 
oughly disinfected before being occupied by anyone else. 

Ophthalmia Neonatorum. 
This disease is identical with gonorrheal ophthal- 
mia, being caused by the same micro-organism, the gono- 
coccus. It occurs in infants ; hence the name, ophthalmia 



OPHTHALMIA NEONATORUM. 



35 



neonatorum, — ophthalmia of the newborn. The symp- 
toms are the same as in gonorrheal ophthalmia, but, as 
a rule, not as severe; furthermore, the eyes of infants 
withstand the inflammation better than the eyes of adults. 
Where ophthalmia neonatorum is seen in time, within 
forty-eight hours after infection, a favorable prognosis may 
be given. This is not so in adults when infected; no 
matter how soon the disease comes under observation or 
how energetic the treatment pursued, the vision of many 
eyes is destroyed by it, and the prognosis should always be 
a guarded one. For instance, I have known a nurse to lose 
her eyes as the result of gonorrheal ophthalmia contracted 
from nursing an infant with ophthalmia neonatorum, the 
infant in the meantime recovering with good vision. 

Ophthalmia neonatorum is contracted from the genital 
organs of the mother during parturition, or immediately 
afterward when the child is bathed. Every obstetrical nurse 
should be taught this fact. The vagina of every parturient 
woman who has a vaginitis should be douched with a warm, 
antiseptic solution (1 teaspoonful of carbolic acid to a 
quart of water) just before delivery. After birth the child's 
eyes should be washed in water from a small bowl, and not 
from the tub in which the child's body is bathed. After 
the lids have been carefully bathed and dried, by direction 
of the doctor in charge, 1 drop of a 2 per cent, solution of 
nitrate of silver should be dropped between the lids into the 
eyes, as first suggested by Creole, and especially should this 
be done if there has been any vaginitis whatever in the 
mother. By this method, in the Lying-in Hospital of Leip- 
zig, Crede reduced the number of cases of ophthalmia neo- 
natorum from 10.8 per cent, (which prevailed before his 
method was used) to 0.2 per cent. With such a showing, it 
seems to me the doctor's duty to order and the nurse's duty 



30 



EYE NURSING. 



to follow this method of treatment is imperative in every 
case of childbirth. And this, no matter whether there is a 
vaginitis in the mother or not. Even if there is no disease 
of the eye, 1 drop of a 2 per cent, solution of silver nitrate 
does no harm; and often, as shown by statistics, does a great 
deal of good by preventing the disease. In the last few 
years, argyrol, in 25 per cent, solution, dropped into the 
infant's eyes immediately after birth, has been a favorite 
remedy with many physicians. 

The nursing of an infant's eyes affected with ophthal- 
mia neonatorum is about the same as that followed in the 
care of an adult with gonorrheal ophthalmia, differing 
somewhat in but one or two particulars. When but one 
eye is affected, a protective bandage should be applied in- 
stead of the Buller's shield, which latter would likely be 
pulled off by the little patient. Again, the lids are very 
small and much more difficult to handle, and it is often 
necessary, on this account, to use a very small and delicate 
lid retractor to elevate the upper lid in order to cleanse the 
eye properly. To introduce this retractor under the upper 
lid without injury to the eye it is necessary to place the 
forefinger of one hand on the skin of the upper lid, about 
% inch above its free margin, and make gentle traction. 
This lifts the free margin of the lid- from the eyeball when 
the retractor can be gently introduced under it. Once 
under, the lid can be held up out of the way while the eye 
is cleansed. 

If the swelling of the lids is so great that the retractor 
cannot be easily introduced, a canthotomy should be per- 
formed by the surgeon; after which it is quite an easy 
matter for the nurse to evert the lids and cleanse the eyes. 
The canthotomy is of direct benefit also, as pointed above, 
by taking pressure of the eyelid off the eyeball, and by 



OPHTHALMIA NEONATORUM. 



37 



reason of the local bloodletting. Complications, as ulcera- 
tion of the cornea, should be treated in the same manner 
as when occurring in gonorrheal ophthalmia in adults. 

Perhaps 95 per cent, of all eyes affected with ophthal- 
mia neonatorum should be saved with useful vision, if 
only seen in time. Unfortunately many of the poorer 
classes in large cities are attended by midwives during con- 
finement, and the infant is often allowed to go for days or 
weeks with a "cold in the eyes" before the child is brought 
to a doctor. This so-called "cold in the eyes" only too 
often is ophthalmia neonatorum, and frequently the child's 
eyes arc hopelessly lost or greatly injured when first seen by 
the doctor. For this reason, this disease, which is easily 
prevented when Crede's method is used, and which is so 
amenable to treatment, when seen in time, is the cause per- 
haps of one-sixth of all cases of blindness. A rather sad 
commentary in this day of antiseptic and aseptic surgery ! 

In the State of New York a law has been passed mak- 
ing it a felony on the part of a midwife or other attendant, 
not a doctor, if sore or inflamed eyes in a newborn infant is 
not reported at once to a doctor. And the punishment may 
be a fine, or imprisonment, or both. 



CHAPTER III. 



MEMBRANOUS CONJUNCTIVITIS (CROUPOUS AND 
DIPHTHERITIC). 

Croupous Conjunctivitis — Diphtheritic Conjunctivitis — Trau- 
matic Membranous Conjunctivitis. 

Clinically we recognize two varieties of membranous 
conjunctivitis: croupous and diphtheritic. Considered 
from their microbic origin, however, the distinction or dif- 
ferentiation between the two forms is not so easily made ; 
for the Klebs-Loeffler bacillus, which is supposedly the 
cause of every case of diphtheritic conjunctivitis, is some- 
times absent in the most virulent clinical forms of the 
disease, while the same bacillus is sometimes present in the 
mildest cases of croupous conjunctivitis. The history of 
the case and clinical appearances must be depended upon, 
therefore, in a large measure, in arriving at a correct diag- 
nosis in these cases. All such cases should be isolated from 
the start, and especially so if there is any suspicion of the 
diphtheritic form being present, since this latter variety is 
highly contagious. Every nurse should be familiar with the 
symptoms (both the local and general) of membranous con- 
junctivitis: first, for the benefit of the patient, and, sec- 
ond, for her own protection and the safety of the public. 

Croupous Conjunctivitis. 

The symptoms in the early stage of the disease are 
burning, pain, redness, and swelling of the eyelids, as in 
an ordinary purulent conjunctivitis. On the second or 
third day, however, a grayish-white membrane forms on the 

(38) 



CROUPOUS CONJUNCTIVITIS. 



39 



conjunctival surface of the lids and in the deeper folds 
(culs-de-sac) of the conjunctiva covering the eyeball itself. 
This membrane may be in small patches or cover the whole 
surface of the conjunctiva of the lids. As a rule, it can be 
wiped off easily with a pledget of cotton, leaving a raw 
surface beneath, which sometimes bleeds. The superfical 
position of this membrane, it being confined to the epithe- 
lial layer of the conjunctiva, and the ease with which it can 
be removed, distinguishes this form of membranous con- 
junctivitis from the true diphtheritic variety. In the latter 
disease the membrane is really an exudate into the deeper 
layers of the conjunctiva and cannot be wiped off at all. 

Again, in croupous conjunctivitis, the lids, though 
swollen and red, do not become stiff and of a "leathery" 
hardness as in the true diphtheritic form of the disease. 
The general or systemic symptoms also are much milder in 
croupous than in diphtheritic conjunctivitis. 

Three or four days after the inception of croupous 
conjunctivitis, the membrane begins to loosen and come 
away, sometimes in small pieces and at times in a mass, 
when the disease assumes more or less the character of a 
purulent conjunctivitis, and is to be treated and cared for 
as such. The membrane may re-form one or several times. 

As the disease is contagious (the streptococcus usually 
being present), the patient is to be isolated, and, if but one 
eye is affected, the other is to be protected by a Buller 
shield or bandage. In the early stages of this disease, 
caustics or strong applications of any kind (as silver 
nitrate, bichloride of mercury, etc., in strong solutions) 
are to be avoided, because these preparations themselves, 
in concentrated form, are capable of forming membranes 
on the conjunctiva. All that is necessary for the nurse 
to do, after isolating the patient and protecting the eye, 



40 



\:\ E M RSING-. 



is to keep the affected eye clean with a saturated solution 
of boric acid, and apply cold cloths to the eye in the very 
early stage of the disease. After the second day, if there 
is still pain, hot applications should be made in place of 
the cold, as the vitality of the eyes in these cases is reduced 
and cold has a tendency to reduce it even further. The 
membrane should be wiped gently from the lids once a 
day. This can be done as follows: Evert the upper lid; 
then, with a piece of cotton wrapped on an applicator and 
moistened in boracic acid solution, rub the membrane off 
of the palpebral conjunctiva, beginning at the border of 
the lid, and carrying the point of the applicator into the 
cul-de-sac so as to remove the membrane from that position. 
If the membrane does not come awa}^ fairly easily, do not 
persist too energetically, but let it alone till the following- 
day, when a second attempt may be made. In fact, the 
membrane will loosen and come away of its own accord 
after a few days. It is better, however, to facilitate mat- 
ters if it can be clone without injury to the eye. 

The use of peroxide of hydrogen, even in the weakest 
solution, should not be used to remove these membranes, as 
its use may cause abrasion of the corneal surface, with con- 
sequent ulceration and infection of that portion of the 
eye, a mishap studiously to be avoided. When the disease 
passes into the purulent stage, it is to be cared for in ex- 
actly the same way as is a purulent conjunctivitis. 

Dip 1 1 theritio Conjunctivitis. 
In this variety of membranous conjunctivitis the 
symptoms are much more severe than in the croupous 
form just described. The pain is much more intense and 
the lids are not only swollen and tender to the touch, but 
are dense and hard, and it is impossible to evert them. 



DIPHTHERITIC CONJUNCTIVITIS. 



41 



The membrane in this disease is really an infiltration into 
the conjunctiva, and cannot be wiped off. It may affect 
only small areas of the conjunctiva, but may cover it 
entirely. The patches of infiltration have a grayish color, 
but when the entire conjunctiva is involved it assumes a 
very pale or "lardaceous" appearance, due to the infiltrate 
pressing on the blood-vessels and diminishing the normal 
blood supply. It is this very feature of the disease that 
makes it so dangerous. The cornea depends for its nutri- 
tion on the blood from the conjunctiva and subconjunc- 
tival vessels, and when the infiltration is very extensive the 
cornea often sloughs, in part or in whole, despite all efforts 
to prevent it. 

Patches of the conjunctiva may slough away, leaving 
a granular surface and later scar tissue. The discharge 
from the eye in this disease is very slight: in the earliest 
stage of a watery or mucous nature, in the infiltration 
stage there is practically no discharge, while in the latest 
stages it may assume a purulent character. 

It should ever be borne in mind by the nurse that 
diphtheritic conjunctivitis is but a local manifestation of 
a systemic disease. Whenever she notices any membranous 
patches, on the conjunctiva, patches of a similar nature 
should be looked for in the throat and in the nose, for the 
throat, nose, and eye are often affected simultaneously. 

The general symptoms in this affection are much more 
severe than in croupous conjunctivitis. The temperature 
is elevated, the pulse quicker, and the patient markedly 
depressed. These marked general symptoms, together with 
the local symptoms of intense pain in the eyeball and stiff, 
leathery condition of the eyelids should point to the nature 
of the trouble. In the very early stages of the disease, 
however, before infiltration of the conjunctiva has occurred 



42 



EYE NURSING. 



and hardness and stiffness of the lids manifested them- 
selves, it is difficult if not impossible to distinguish the 
graver from the milder disease. In every instance, there- 
fore, where a nurse has charge of a child, or children, as 
they often have, and any membranous formation appears 
on the conjunctiva, it should be reported to the parents 
or those in authority, and the child in the meantime 
isolated. 

I have dwelt somewhat at length on the symptoms 
and manifestations of croupous and diphtheritic conjunc- 
tivitis, in order that the nurse may recognize or at least 
suspect the nature of these affections when she comes in 
contact with them, as she often does. 

The protection of the fellow-eye, if but one is affected, 
the isolation of the patient, and the institution of prompt 
treatment depend upon the early recognition of the nature 
of the disease. Only too often is the disease allowed to 
gain a firm hold and others exposed to the infection before 
the real nature of the affection is known. 

The nurse's first duty in a case of diphtheritic con- 
junctivitis, after the patient has been isolated, is to apply 
a protective shield or bandage to the unaffected eye, if but 
one is involved. The method of doing this has already 
been described in a preceding chapter, and need not be 
gone into again here. The second important duty in these 
cases is the application of hot fomentations. Cold applica- 
tions should not be applied in diphtheritic conjunctivitis. 
The vitality of the patient and of the eye is much reduced 
already, and cold applications make matters worse. Heat, 
on the other hand, sustains the vitality, and at the same 
time relieves the pain, and in a measure softens the thick- 
ened and stiffened eyelids. Hot saturated boracic acid, or 
salt solutions, by means of pledgets of cotton soaked in 



DIPHTHERITIC CONJUNCTIVITIS. 43 



them, should be applied to the eyes thirty minutes out 
of every second hour during the day, and half this often 
during the night. The patient is not disturbed so fre- 
quently during the night, in order that he may obtain a 
sufficient amount of sleep, for it is just as important for 
the patient to have rest and concentrated diet as local 
treatment ; more so, perhaps. In fact, every measure that 
sustains vitality, general and local, is to be resorted to. 
Local remedies or applications, other than the hot fomen- 
tations just mentioned, are of but little value in the treat- 
ment of this malady. All irritating applications of what- 
ever nature are to be rigidly avoided, as they do harm 
rather than good. There is but little to be done in the 
way of cleansing the eye, as in the early and middle stages 
of the disease there is but scant secretion, and this is from 
the portion of the conjunctiva not infiltrated. The mem- 
brane, or, to be more accurate, the infiltrate, cannot be 
wiped off and is gotten rid of by absorption. In the later 
stages of the disease there is more or less of a purulent 
secretion, and this must be washed away frequently, just 
as in purulent conjunctivitis, with boracic acid solution. 
Topical applications of silver nitrate, 10 grains to the 
ounce solution, may be used sparingly at this stage, being 
limited to that portion of the conjunctiva not affected by 
the infiltrate. Where ulceration of the conjunctiva has 
taken place, the lids should be separated from the eyeball 
several times a day, and, as this ulceration usually occurs 
in the later stages of the disease, the lids are usually 
pliable enough to be lifted away from the eyebal 

The membrane may reappear in these cases, especially 
if irritating applications have been made to the conjunctiva. 

Ulceration of the cornea, in part or the whole, fre- 
quently occurs in diphtheritic conjunctivitis. At the first 



44 



EYE NURSING. 



appearance of such a complication, atropine is to be in- 
stilled, — of course, according to the surgeon's directions; 
hot fomentations persisted in, and the general condition of 
the patient sustained by fluid diet, tonics, etc. 

Incidentally, it may be remarked that no cauterization 
of the corneal ulcer by means of the actual cautery, carbolic 
acid, nitric acid, or other destructive agents should be un- 
dertaken, especially in the early stages, since the ulceration 
is due to a lowered vitality and-cutting off of nutrition to 
the cornea by the infiltrate, and not to infection. In the 
later stages such measures may be cautiously used. 

Diphtheritic conjunctivitis is met with most frequently 
in babies after six months of age and young children, 
though occasionally in the adult. In the latter instance, it 
is often contracted by doctors, nurses, and attendants, from 
children suffering with faucial diphtheria, by having the 
membrane or parts of it coughed into the eye while attempt- 
ing to cleanse the child's throat. If active measures are 
at once adopted, usually infection can be prevented, and I 
have prevented it on one occasion where a doctor had a 
large piece of membrane coughed directly into his eye. The 
eye is cleansed thoroughly with a solution of bichloride of 
mercury (1 to 5000), then 2 or 3 drops of a 1 per cent, 
solution of silver nitrate is dropped into the eye, and finally 
4 or 5 drops of sweet oil are dropped into the eye. 

As to the general care of the patient and nursing con- 
nected with faucial diphtheria, the administration of the 
antitoxins, etc., see the chapter on faucial diphtheria in 
Part II ; also the chapter on Serums and Vaccines. 

Traumatic Membranous Conjunctivitis. 
This may result from applications of caustics to the 
conjunctiva, strong solutions of silver nitrate or the solid 



TRAUMATIC MEMBRANOUS CONJUNCTIVITIS. 45 



stick, carbolic acid, nitric acid, or to dusting the powdered 
jequirity bean into the eve in the treatment of trachoma, 
and always occurs after the operation of "expression" of 
trachoma, if the operation is at all thorough. 

Where the membrane is the result of caustics, the only 
treatment and care necessary is to discontinue the caustic 
and keep the eye cleansed with boracic acid solution. Sweet 
oil may be dropped between the lids and the eyes protected 
with a shade or patch. Care should be taken that no adhe- 
sions occur between the lids and the eyeball. 

Where the powdered jequirity bean is dusted into the 
eye, in the treatment of old trachoma with pannus, the eye- 
lids become markedly swollen and edematous, the con- 
junctiva intensely congested, and the eye very painful in 
about twelve hours after the powder is put into the eye 
and lasts from forty-eight to seventy-two hours. Iced 
cloths are applied fifteen minutes every second hour, and 
the secretion, wdiich is very scanty, is to be washed away 
with boracic acid solution. At the end of the second or 
third day a dirty-grayish membrane is formed covering the 
entire conjunctiva and even the cornea. This breaks down 
and comes away a piece at a time, or occasionally a east of 
the entire lid is removed. As this membrane loosens it 
should be washed away with boracic acid solution and 
rubbed off gently with cotton wrapped on an applicator. 
Usually the membrane is entirely cleaned away in ten 
days' to two weeks' time. Iced cloths are not to be used 
after the pain and intense swelling are gone. The patient 
is to be put to bed and the eyes looked after as carefully as 
if the patient had croupous or purulent conjunctivitis. 

The membrane that follows "expression" of trachoma 
is to be treated exactly in the same manner as indicated 
above. For the first few days after the operation is per- 



46 



EYE NURSING. 



formed, iced cloths are to be applied; then, when the 
membrane begins to loosen, it should be washed away or 
rubbed off with cotton. If this is not done, the membrane 
organizes, forms dense connective tissue (scar tissue), and 
leaves the lids in a very undesirable condition, which may 
result in curving of the lids inward toward the eye (en- 
tropion) with the lashes sweeping the cornea. 



CHAPTER IV. 



SOME OF THE NON-CONTAGIOUS DISEASES OF THE EYE 
CALLING FOR THE SERVICES OF A NURSE. 

Hordeolum— Blepharitis Marginalis— Phlyctenular Conjunc- 
tivitis — Ulcerative Keratitis — Iritis — Cyclitis — Iridocyclitis — 
Sympathetic Ophthalmia — Glaucoma — Panophthalmitis. 

Hordeolum (Stye). 

This is one of the commonest affections of the eyes. 
A stye is not of serious import in itself, but often gives the 
patient acute pain and much annoyance. It is nothing 
more or less than a little boil or abscess at the root of an 
eyelash. Any treatment that aborts the process or alleviates 
the pain is very grateful to the patient. When seen early, 
epilation or pulling of the eyelash, at the root of which the 
abscess is forming, and the application of hot fomentations 
relieve the pain and frequently abort the disease. If the 
st}'e is not aborted, the hot applications shquld be continued 
several times a day until the stye is "ripe" for opening, 
when it should be lanced by the surgeon, the contents gently 
pressed out with the fingers and hot applications applied 
a day longer. Where a person is subject to frequent re- 
currence of styes, the eyes should be examined for glasses, a 
refractive error sometimes being the exciting cause. 

Blepharitis Marginalis. 

Inflammation of the borders of the lids is a very com- 
mon affection of the eyes. It presents itself under two 
forms : blepharitis squamosa and blepharitis ulcerosa. In 
the squamous variety the edges of the lids are reddened and 

(47) 



48 



EYE NURSING. 



covered with dry scales; ift the ulcerative, the edges of 
the lids are not only reddened, but the eyelashes are tufted 
together with dried crusts.- When these crusts are removed 
small ulcers are found beneath them, around the roots of 
the eyelashes. 

If the disease has lasted for a long time it may cause: 
a chronic conjunctivitis; irregularity of the lashes (wild 
hairs, or trichiasis), causing them to sweep the cornea; 
total loss of the eyelashes (baldness of the lids, or mada- 
rosis) ; thickening of the edges of the lids, and eversion of 
the lower lid (ectropion). 

The exciting causes of the disease are : much weeping ; 
bright light; smoke; dust; closure of the lacrymo-nasal 
canal, causing tears to run over the eyelids; astigmatism, 
and excessive use of the eyes. General causes leading to the 
disease are scrofula, tubercular affections, etc. When only 
one eye is affected we should look for a local cause, as stop- 
ping of the tear-duct. 

Treatment. — The local treatment consists, first, in 
cleansing all scales and crusts from the edges of the lids. 
This may be done by bathing the lids with a warm solution 
of carbonate of soda (2 drachms of soda to the pint of 
water) for ten minutes, rubbing the crusts off with a piece 
of cotton saturated in the solution. In the very severe cases, 
where the lids are thickened, the eyelashes should be pulled 
oat with cilia forceps, and the little abscesses at their 
bases touched with a solution of nitrate of silver (2 per 
cent.). After the lids are thoroughly cleansed in the man- 
ner just described, an ointment of some kind should be 
rubbed on the edges of the closed lids. Of the various 
ointments, the yellow oxide of mercury (Pagenstecher), % 
to 1 per cent, (the base of vaselin or lanolin), perhaps is 
the best. In very sensitive eyes the ammoniated mercury 



LYMPHATIC CONJUNCTIVITIS. 



49 



ointment, the same strength as the yellow oxide, may be 
used. As a base for these ointments, equal parts of vaselin 
and lanolin are to be preferred. In obstinate cases the red 
oxide of mercury ointment and tar preparations may be 
used, but they are usually too irritating. As a rule, the 
milder the ointment, the less irritation and the quicker the 
cure. In these mercurial ointments, too, it is altogether 
essential that they be well made, the mercury finely pul- 
verized, and no grains left in it. A few drops of sweet 
oil added to the pow dered mercury and rubbed with it be- 
fore it is added to the base facilitates this and makes a 
smoother ointment. No more than % ounce of ointment 
should be prescribed at one time, as it soon becomes rancid, 
when it should be renewed. 

The general treatment consists of placing the patient 
in better hygienic surroundings, which unfortunately can 
seldom be done, as usually the patients are from the poorer 
classes; building up the system with tonics, as the syrup 
of the iodide of iron, syrup of hypophosphites, codliver-oil, 
etc. ; and placing the patient on a simple nutritious diet. — 
milk, bread and butter, oatmeal, fresh meat once a day, 
eggs, etc. All sweets and pastry should be excluded from 
the diet. 

Phlyctenular ok Lymphatic Conjunctivitis. 

Phlyctenular keratitis may be discussed under this 
heading also, as it is essentially the same disease, the con- 
junctival epithelium extending over the cornea and forming 
its anterior layer, the one chiefly affected in this disease. 

The disease occurs most frequently in young children 
and up to puberty — rarely before 1 year of age or in adults. 
Children in poor hygienic surroundings with inadequate 
nourishment and ecrofulous and tubercular taint are most 

4 



50 



EYE NURSING. 



subject to it. Unlike the other forms of inflammation of 
the conjunctiva, which are diffuse in character, this affec- 
tion is circumscribed, or focal, in nature; that is, small 
spots of the conjunctiva or cornea are affected while the 
rest remains .in a quiet state. 

The favorite location of these phlyctenules is at the 
limbus of the conjunctiva ; that is, where the conjunctival 
epithelium incroaches upon the cornea. From one to a 
half dozen small, red, somewhat elevated spots, about the 
size of a pinhead' (sometimes larger, sometimes smaller), 
appear on or near the limbus of the conjunctiva. Small 
leashes of blood-vessels, triangular in shape, run to each 
phlyctenule, or rather nodule, as there is^ in fact, no vesicle, 
but simply an elevation of the epithelium by an exudate of 
round cells beneath the epithelium. After a few days' time 
(from one to three) the epithelium at the top of the eleva- 
tion breaks down, leaving a small, grayish ulcer. This 
heals under favorable conditions in from one to two weeks' 
time. The same holds true when they are on the cornea, 
and without leaving opacities. When neglected and the 
ulcer extends into the true corneal tissue, opacities are left 
which never clear away, and the sight is impaired. Some- 
times these small ulcers take on a serpiginous character; 
that is, extend across the cornea, drawing a leash of blood- 
vessels after them, and leaving a bandlike opacity when 
they heal. Phlyctenular may appear on the conjunctiva 
(ocular) alone, when they are large and usually few in 
number; they may appear on the cornea proper, or at the 
limbus of conjunctiva, as they do most frequently. They 
may be very small and surround the cornea entirely. 

The most marked symptoms of phlyctenular conjunc- 
tivitis, outside of the phlyctenules themselves, is the great 
fear of light (photophobia) which is present in almost 



LYMPHATIC CONJ UNCTIVITIS. 



51 



every r case; and, second, the spasm of the orbicular or lid 
muscles. Children will hide their faces in dark corners, 
in the bedclothes to avoid the light, and they shut the eye- 
lids tightly for the same reason and on account of the irri- 
tation of the cornea and conjunctiva. Often accompanying 
this disease the edges of the eyelids are inflamed, and even 
the outer surface of the lower lid and the nasal mucous 
membrane and the upper lip have an eczematous eruption, 
which must be treated along with the eye affection. 

Treatment. — Locally, the best and most frequently 
used remedy is the Pagenstecher ointment of the yellow 
oxide of mercury (1 to 2 per cent.), which is placed on 
the everted lower lid with a small spatula or with the tip 
of the finger, then the lid is allowed to close and the oint- 
ment is rubbed into the eye with the tip of the finger over 
the closed lids. This is done once a day. Calomel dusted 
into the eye once a day with a camel's-hair brush is an- 
other favorite remedy in these cases. If there is marked 
inflammation of the eyes and the ulcers are rather deep, it 
is better to treat the eyes for a few days with atropine and 
hot water fomentations until the inflammation is reduced 
somewhat, when the above remedies may be applied. The 
eruption on the outer surface of the lids and about the nose 
is treated by having the scales washed off and the yellow 
oxide of mercury salve rubbed on the affected surfaces. 
Painting the surface about the nose with a solution of 
nitrate of silver (10 grains to the ounce) often is of great 
benefit. 

For relief of the spasm of the lids and to make the 
patient open the eyes, dipping the face into a basin of cold 
water three or four times a day is the best remedy. Small 
children are wrapped in a towel or sheet, held under one 
arm, and their faces pushed into the water and held there 



52 



EYE NURSING. 



ten to twenty seconds with the other hand. Usually the 
child holds the eyes open for an hour or two after this duck- 
ing. If the photophobia is intense, a solution of sulphate 
of eserin (% grain to the ounce) may he used twice a day, 
and dark "lasses or a shade worn. Under no circumstances 
should the child he allowed to hide in dark corners or its 
face in the bedclothes. 

General treatment consists in building the patient up 
with tonics, as the syrup of iodide of iron, syrup hypophos- 
phite compound, codliver-oil, etc. ; placing the patient in 
the best hygienic surroundings; and, when it is possible, 
getting the patient into the open air two or three hours a 
day. The food should be simple; milk, bread and butter, 
soups, eggs, fresh meat once a day, etc., while all sweets 
are discontinued. 

The eyes of these patients usually get well in from one 
to four or five weeks' time, but unfortunately there is a 
marked tendency to recurrence of the disease, and, when 
once affected, the patient is liable to fresh attacks until 
puberty is reached, and exceptionally even later in life. 
The sight may be greatly impaired if many attacks occur or 
if treatment is neglected. 

Ulcerative Iyer at it i s. 

Three of the severer types of ulceration of the cornea 
will be spoken of here; in particular, serpiginous ulcer 
(ulcus serpens); perforating ulcer; and the rodent ulcer 
(ulcus rodens). The subjective symptoms of ulceration of 
the cornea are : pain, fear of light, tearing of the eyes, 
closing of the lids to keep the light out, and more or less 
interference with vision. Objectively, in the early stage of 
ulceration, a facet, smaller or larger as the case may be, is 
seen on the cornea. If the ulcer is a clean one, the bottom 



ULCERATIVE KERATIT] 8. 



53 



and edges of the facet are very slightly grayish and there is 
but slight infiltration of the neighboring cornea. If it is a 
foul nicer, the bottom and edges of the ulcer are covered 
with grayish matter, and the cornea next the ulcer is in- 
filtrated and of a grayish color. Sometimes pus forms in 
the anterior chamber, which is called hypopyon. Usually 
there is an iritis present when this complication happens, 
with intense pain and circumcorneaJ injection. 

In serpiginous ulceration of the cornea the ulcer is 
clean on one side and dirty or foul on the other. On the 
clean side (which is nearest the periphery of the cornea) 
blood-vessels are thrown out to it from the corneal limbus 
and it heals; while on the other side the grayish infiltrate 
keeps extending into the cornea, the corneal tissue break- 
ing down (ulcerates), and this ulceration may creep or ex- 
tend entirely across the cornea. The blood-vessels which 
are thrown out to the clean side of the ulcer follow in the 
wake of the ulcers and heal it. When the ulcer finally 
heals, a band or ribbonlike opacity is left, which, though it 
may not extend deep into the corneal surface, often impairs 
vision very much on account of its extent. 

Rodent nicer of the cornea affects the superficial lavers 
of the cornea and is marked by severe inflammatory symp- 
toms. It usually starts at or near the margin of the cornea 
with edges that are undermined and of a dirty-grayish color. 
This undermining and breaking down of the rim of cornea 
immediately surrounding the ulcer progresses interruptedly 
(for often tbe edges of the ulcer clear up as if healing were 
about to take place, and then it starts again) until fre- 
quently the entire surface of the cornea is affected. A 
diffuse opacity covering the entire cornea results and use- 
ful vision is destroyed. Unfortunately both eyes may be- 
come affected. The disease occurs in old people. 



54 



EYE NURSING. 



Treatment. — Local treatment consists in protecting 
the eyes from bright light, the instillation of atropine, the 
application of hot fomentations, and, chiefly and most effi- 
cient, cauterization of the ulcer by the surgeon with the 
actual cautery, the galvanocautery, or with pure carbolic 
or nitric acid. In ulcus serpens the foul side of the ulcer 
only should be cauterized. 

The general treatment is directed to toning the patient 
up with tonics, concentrated fluid diet, rest, massage, and, 
what often proves of marked benefit in these cases, a series 
of hot baths. Care should be exercised in giving hot baths, 
especially if the patient has a weak heart. The bowels 
should be kept in order. 

Perforating Ulcer. — Ulceration of the cornea follow- 
ing violent inflammation of the conjunctiva, as after gon- 
orrheal ophthalmia, diphtheritic ophthalmia, etc., often 
results in perforation of the cornea with prolapse of the 
iris into the wound, and sometimes with entire destruction 
of the cornea with loss of the lens and vitreous, and fol- 
lowed at times even with panophthalmitis. Perforating 
ulcer of the cornea is a serious disease, the iris often falling 
forward into the opening, becoming adherent, and when the 
wound heals leaves a dense, white opacity (leu coma) inter- 
fering greatly with vision. Sometimes this leucoma is so 
thinned that it bulges forward, forming a staphyloma of 
the cornea. When hypopyon complicates ulceration of the 
cornea and is not resorbed quickly, paracentesis of the cor- 
nea should be practised and the pus evacuated ; because, if 
allowed to organize, it blocks the pupil and may bind the 
cornea to the iris, and does great damage to vision and the 
eyeball in this way. The nurse is required to apply hot 
fomentations (moist) thirty minutes out of every two 
hours, and the instillation of a mydriatic as directed. Often 



IRITIS. 



55 



a bandage is indicated, when it has to be changed frequently 
to allow the application of hot water. The general condi- 
tion of the patient and the giving of baths all come under 
the nurse's immediate direction. 

Iritis, Cyclitis, Irido-cyclitis, Sympathetic 
Ophthalmia. 

Iritis is an inflammation of the iris; cyclitis is an 
inflammation of the ciliary body (ciliary muscle and proc- 
esses), while irido-cyclitis is an inflammation of both the 
iris and ciliary body. Irido-cyclitis, when transferred from 
one eye to the other, as after an injury to the one eye, is 
called sympathetic ophthalmia. Iritis, cyclitis, and irido- 
cyclitis may be primary or secondary in nature. When 
primary, they are usually due to some general disease, as 
syphilis (acquired), rheumatism, infectious diseases, etc.; 
or they may be due to traumatism, and the second eye may 
be affected sympathetically. When of a secondary nature, 
they most commonly follow inflammations of the cornea. 

iritis. 

The objective symptoms of iritis of the plastic or exu- 
dative type (following syphilis, and about 65 per cent, or 
more of all cases are such) are: (1) discoloration of the 
iris, in blue eyes to a greenish or greenish-yellow hue, and 
in dark eyes to a "muddy" or lighter brown, as compared 
with the fellow-eye; (2) at times yellowish-red nodules 
appear on the borders of the iris, 1 to 4 or 5 millimeters 
in diameter, and varying in number from one to a half 
dozen or more ; (3) contraction of the pupil and immobility 
of the iris; (4) redness of the eyeball, especially that part 
of it immediately back of the cornea; (5) cloudiness of the 



56 



EYE NURSING. 



aqueous humor and, at times, in severe cases, the presence 
of pus in quantity in the anterior chamber (hypopyon) ; 
(6) a gray exudate filling the pupil (occlusion of the 
pupil) ; (7) impairment of vision ; (8) lacrymation. Exu- 
dates may be formed on the posterior surface of the iris 
binding it to the anterior surface of the lens capsule, which 
are called posterior synechiae. If these synechias bind the 
entire pupillary margin to the lens capsule (seclusion of 
the pupil) it is called posterior annular synechiae. This is 
seen only in the latest stages of the disease, and manifests 
itself by a "ballooning" of the iris; that is, the pupillary 
margin of the iris being bound to the lens capsule, the 
secretions back of the iris, being unable to escape into the 
anterior chamber, push the middle zone of the iris forward. 

The subjective symptoms of iritis are: (1) pain in 
the eye, as a rule most severe at night; (2) photophobia 
(fear of light) ; (3) pain in the temple and side of the 
head on the corresponding side as the affected eye. 

CYCLITIS. 

Cyclitis without a complicating iritis, except in a 
chronic form (described as serous iritis), is a rare affection. 
The symptoms of inflammation are very mild ; the pupil is 
dilated, the anterior chamber is deep, the aqueous humor is 
a little hazy, and often there is a deposit of small, grayish 
spots on the posterior surface of the cornea, and at times 
the eye has a plus tension. 

IRIDO-CYCLITIS. 

Irido-cyclitis, being an inflammation of the iris and 
the ciliary body, has the symptoms' of an iritis, which have 
been enumerated above, and, in addition, the following 
symptoms may be present: (1) edema of the upper lids; 



SYMPATHETIC OPHTHALMIA. 



.-,7 



(2) excessive tenderness of the eye to the touch, especially 
over the ciliary region; (3) excruciating pain, which may 
be attended in severe cases with vomiting and elevation of 
temperature; (4) marked disturbance of vision, due to 
opacities in the vitreous and deposits on the posterior sur- 
face of the cornea; (5) increased depth of the anterior 
chamber due to binding down of the entire posterior sur- 
face of the iris to the lens capsule; (6) increased tension 
of the eye, followed in the latest stages of the disease by 
diminished tension. 

SYMPATHETIC OPHTHALMIA. 

This disease, irido-cyclitis, may be transferred from 
one eye to the other (especially if it is due to a trauma- 
tism), when it is called sympathetic ophthalmia, or sympa- 
thetic irido-choroiditis. Sympathetic ophthalmia is a very 
serious disease of the eye, and when once thoroughly estab- 
lished rarely subsides until the sight of the sympathizing 
eye is entirely destroyed. It follows most frequently an 
irido-cyclitis which has been produced in the injured eye 
by a penetrating wound of the ciliary region or by a foreign 
body being lodged in the eye. The disease may appear as 
early as the second week, but usually not until from four to 
six weeks after the injury to the offending eye, when the in- 
flammation in the injured eye is at its height. It may ap- 
pear, however, years after the injury, especially when for- 
eign bodies have been lodged in the eye. These may be- 
come loosened, set up a fresh inflammation of the injured 
eye, and a sympathetic inflammation in the other. No 
wound in the ciliary region of an eye, or a foreign body 
lodged in an eye, is to be regarded as free from inciting 
sympathetic ophthalmia in the fellow-eye, even years after 
the traumatism has occurred, 



58 



EYL NURSING. 



Sympathetic ophthalmia is characterized by a prodro- 
mal stage and by its marked tendency to recur. Failure of 
the power of accommodation (in the sympathizing eye) is 
one of the very first signs of the disease. The patient, 
though he may be a young subject, finds he has to hold read- 
ing matter farther from his eyes than usual in order to 
read ; secondly, the eye becomes sensitive to light or even 
painful; thirdly, there is lacrymation; and finally some 
redness of the eye. This is termed sympathetic irritation. 

As a rule, unless this condition is speedily relieved by 
quieting the inflammation in the injured eye, it develops 
into an irido-choroiditis, marked by circumcorneal injec- 
tion, contraction of the pupil, clouded aqueous humor, but 
rarely with hypopyon; there are also pain, photophobia, and 
retraction of the iris in severe cases. This condition may 
last from two to several weeks, and then subside, but almost 
without exception the attack is repeated and repeated until 
the sight is totally destroyed. In fact, if the sight is not 
entirely destroyed in the injured eye, it may retain more 
vision than the sympathizing eye. The surest method of 
preventing sympathetic inflammation is to enucleate the 
injured eye before the inflammation is well established in 
the uninjured eye; that is, when the symptoms of sym- 
pathetic irritation set in ; for when once fully developed 
enucleation of the injured eye rarely relieves it. 

The Treatment of Iritis, Iridocyclitis, and Sym- 
pathetic Irido-cyclitis. — In iritis the first and most im- 
portant step in treatment is to dilate the pupil, if that can 
be done. A solution of the sulphate of atropine (varying in 
strength from 1 to 3 per cent.) is the drug most relied 
upon. A drop of the solution, usually 1 per cent., should 
be put into the eye every five minutes, extending over a 
period of thirty minutes. If the pupil does not dilate 



SY.M PATHETIC OPHTHALMIA. 



59 



easily, a drop of cocaine solution (1 per cent.) should be 
dropped into the eye along with the atropine, or a few drops 
of adrenalin chloride solution (1 to 1000) may be supple- 
mented. The cocaine and adrenalin solutions (and atro- 
pine to a slight extent) aid in the dilatation of the pupil 
by contracting the blood-vessels of the iris and driving 
the blood from it. In stubborn cases where the adhesions 
are firm, Fuchs advises dropping a small granule of atro- 
pine in substance in the conjunctival sac. 

A powerful cycloplegic of comparatively recent use is 
scopolamine, which is to be used in the same manner as 
the atropine, but in much weaker solution : from % 0 to Y 5 
of 1 per cent, solution. The nurse should always be careful 
to press with her fingers on the lacrymal sac at the inner 
corner of the eye for two or three minutes after instilling a 
mydriatic or myotic into the eye, to prevent an excess of the 
drug going into the nose, where by rapid absorption into the 
general system it may cause annoying and sometimes 
alarming symptoms of poisoning. The patient also should 
be shown how to press over the inner corner of the eyes to 
prevent the above complication. 

If the pupil does not dilate by the use of these meth- 
ods, from two to six leeches should be applied to the temple 
on the side of the affected eye (for the method of applying 
leeches see page 90), or the artificial leech may be used. 
If the pupil still does not yield, a hypodermic injection of 
the muriate of pilocarpine (%o to % grain) causes profuse 
sweating and often aids in dilating the pupil. Hot, moist 
compresses to the eye and hot baths also assist in dilating 
the pupil, as well as alleviating the pain, as does also the 
leeching. In fact, the nurse's chief duty after instilling the 
medicines into the eye will be the application of hot fo- 
mentations. These should be kept up thirty minutes out of 



60 



EYE M USING. 



every two hours during the day and half as often during 
the night if there is much pain. 

The eyes (both) should be shaded from light with a 
light patch or shade, or dark glasses, or the room should be 
darkened. 

After the pupil is once dilated atropine should be used 
once or twice a day to keep it dilated. The bowels should 
be kept open. The diet should be light, no liquors being 
used, and in severe cases the patient should be confined to 
bed. In fact, in iritis of any severity the patient is much 
better off in bed than out, and the disease runs a quicker 
course. 

The general treatment is directed to removing the 
icause. In syphilitic iritis the inunctions of mercury arc 
begun at once, using the oleate of mercury (20 per cent., 
Squibbs), x /-> to 1 drachm being rubbed into the patient 
every night by the nurse with rubber gloves. This should 
be continued until the iritis subsides, ('are should be taken 
not to salivate the patient. Potassium iodide in saturated 
solution may be given at the same time, the dose being in- 
creased from 5 drops, 1 drop a dose, until the effect of the 
medicine is manifested by watering of the eyes, and small 
pimples on the face, when the dose should be lessened. It 
should be given in a full glass of water or milk after meals. 

In rheumatic iritis the salicylates are given and hot 
baths resorted to. 

The treatment of irido-cyclitis is much the same as 
that of iritis. Mydriatics are not so well borne sometimes, 
especially if there is elevation of the tension. In sympa- 
thetic irido-cyclitis the best treatment is prevention, and 
the best prevention is early enucleation of the injured eye 
before actual inflammation starts in the uninjured eye. 
Once started, no treatment is of much avail, though mer- 



GLAUCOMA. 



61 



cury in full doses and sweating by means of pilocarpine in- 
jections may prove of benefit. Very large doses of sali- 
cylate of soda has been recommended in these cases, and 
favorable results reported (Gilford). 

Glaucoma. 

A brief description of acute and inflammatory glau- 
coma is given here that the nurse may not confuse this dis- 
ease with iritis, and that she may not make the great 
mistake of instilling atropine into eyes affected with this 
disease. 

Glaucoma is a complex disease of the eye, characterized 
by hardening of the eyeball, from which hardening or ele- 
vation of tension (pins tension) all the other symptoms 
of glaucoma follow. It may be primary in nature, or sec- 
ondary following injury or disease of the eyeball. In the 
former case it affects both eyes always, but not necessarily 
at the same time, while in secondary glaucoma but one eve 
is affected. 

In primary glaucoma there is usually a prodromal 
stage, which may extend over days, weeks, months, or even 
years before the disease manifests itself in virulent form. 
During this stage the patient has attacks of dimness of 
vision, sees rings round lights, rainbow colored, and has a 
sense of fullness in the eye extending often to the forehead 
and temple. The pupil is slightly dilated and sluggish, the 
tension of the eye is elevated (pins), and there is slight 
redness of the eyeball. These attacks may last for hours, 
completely disappear, and not return again for months per- 
haps. The eye in the meantime resumes the normal condi- 
tion. Then the attacks become more frequent, last longer, 
and finally develop into a full-fledged inflammatory glau- 
coma. The eyeball becomes intensely hard to the touch of 



62 



EYE NURSING. 



the finger through the closed lid, feeling like a stone; the 
eyeball is dusky red in color, with marked edema of the 
conjunctiva often extending to the eyelids; the pupil is 
widely dilated and does not react; there is a greenish re- 
flex from the pupil; the cornea has a steamed appearance 
and is insensitive to touch; the anterior chamber is very 
shallow, while the pain is unbearable. Pain extends to the 
temple and head, and is of the intense neuralgic type, the 
patient often mistaking the disease for neuralgia. At times 
there is rise of temperature and vomiting. The field of 
vision is much contracted and the sight greatly reduced, and 
may be totally destroyed in a few hours' time in the worst 
cases. Such an attack may last for days or weeks, when the 
eye becomes quiet, the pain and redness disappear, and the 
tension much reduced if not entirely normal. If active 
treatment is not instituted, as eserin in oily solution (2 
grains to the ounce) or pilocarpine solution (4 grains to 
the ounce) instilled, or iridectomy performed, the attacks 
recur and the eyesight is slowly, but surely, destroyed. It is 
altogether important that this disease be not mistaken for 
iritis and atropine instilled, as is frequently done (even by 
doctors) to the great detriment of the eye. Dilatation of the 
pupil blocks the canal of Schlemm and increases the trouble. 

The important points of differentiation between 
glaucoma and iritis are as follows: 1. In glaucoma the 
tension is increased and the eyeball is hard. In order to 
detect hardness of the eye, palpate the eyeball over the 
closed lids with the tip of the index finger of each hand; 
then palpate the unaffected eye, and any difference in ten- 
sion of the two is apparent. In iritis the tension is normal. 
2. In glaucoma the pupil is dilated; in iritis the pupil is 
contracted. These two points of differentiation should be 
well fixed in the mind of the nurse. 



PANOPHTHALMITIS. 



63 



The cause of primary glaucoma is little understood. 
Some (von Graefe) attribute it to increased fluid in the 
eye, some (Donders) to irritation of the ciliary nerves, some 
( Stellwag) to increased blood-pressure in the blood-vessels 
inside the eye, while others (Weber and Knies) to dimin- 
ished outflow of fluid from the eye. 

Predisposing causes are: old age, hardening of the 
blood-vessels, obstinate constipation, sudden increase of 
blood-pressure; while women are more frequent sufferers 
than men. The form of the eye itself seems to have some 
effect, as myopic eyes are seldom attacked by glaucoma, 
while the flat hypermetropic eye is. 

Treatment. — When seen early the instillation of 
eserin solution (2 grains to 1 ounce of sweet oil), 1 drop 
every ten minutes for an hour, may prevent an acute attack, 
or, if at its height, may reduce the tension, relieve pain, and 
leave the eye in better condition for performing iridectomy. 
Iridectomy has proved to be the quickest and surest relief 
and even cure of this frightful disease. 

Panophthalmitis. 
As the name indicates, panophthalmitis is an inflam- 
mation involving all the tissues of the eyeball, and even 
the cellular tissue of the orbit and the lids are involved. 
The disease originates usually from an acute traumatic 
purulent choroiditis, or retino-choroiditis ; or it may follow 
a perforating ulcer of the cornea. It may be metastatic in 
nature, following pyemia, measles, scarlet fever, diphtheria, 
influenza, small-pox, meningitis, etc., when it may affect 
both eyes. 

The two most prominent symptoms are: (1) intense 
pain; (2) marked swelling of the eyeball, the tissues of the 
orbit and lids participating in the process. After the first 



64 



EYE NURSING. 



few hours the pain becomes unbearable, unless relieved by 
hot fomentations, opiates, or lancing of the eyeball. The 
pain radiates to the head and is often accompanied by rise 
of temperature and vomiting. The eyeball becomes promi- 
nent ; the conjunctiva intensely congested, edematous, and 
a purplish red ; the cornea hazy ; the anterior chamber rilled 
with pus ; and the lids swollen and red, and tender to the 
touch. 

The nurse's duty in such cases is the application al- 
most continuously of hot fomentations, either in the form 
of linseed poultices or hot, moist applications (water 115° 
F.) by means of pledgets of cotton. 

When the eyeball has perforated or has been split open 
by the surgeon the wound should be syringed every two 
hours with a solution of bichloride of mercury (1 to 2000) 
or of carbolic acid (1 to 150), seeing that the solution gets 
inside the eyeball. . The pain usually subsides quickly after 
the eyeball is once opened. 

The general condition of the patient is to be carefully 
looked after by the nurse, and the pulse, temperature, 
howel movements, etc., charted. 

The prognosis is always unfavorable in panophthal- 
mitis: the eyeball shrinks and the sight is totally lost. 
The disease is due to infection, and various micro-organ- 
isms have been found by microscopical examinations, as the 
staphylococcus aureus and albus and the streptococcus 
pyogenes. 



CHAPTER V. 



REMEDIES AND THEIR APPLICATION. 

Antiseptics — Astringents — Anodynes — Irritants — Counter-irri- 
tants — Caustics — Galvanocautery — Actual Cautery — Cycloplegics, 
Mydriatics, and Myotics — Anesthetics — Miscellaneous Remedies — 
Vehicles — Bases — Solutions — Ointments — Powders. 

The nurse should be familiar with the various reme- 
dies and measures used in the treatment of eye diseases and 
have some knowledge of the nature of their actions, for in 
this way only will she be able to apply them intelligently. 

Antiseptics. 

Antiseptics are a class of remedies used for the pre- 
vention of septic decomposition or inflammation, or for 
arresting the process if already begun. Their efficiency 
depends upon their power to kill the micro-organisms which 
cause the inflammation. 

Boracic acid is a mild astringent powder. It is slightly 
antiseptic in action and causes no irritation whatever to the 
eye. It is used in a solution of from 1 to 4 per cent, for 
cleansing and irrigating the eyes in the various inflamma- 
tory affections. For this purpose it has almost superseded 
all other solutions, and, although only mildly antiseptic in 
action, on account of its unirritating property, it is used 
largely for irrigating the eye just before operations on that 
organ. After the eyeball has been opened, as in cataract 
extraction, iridectomy, etc., it is to be used in preference 
to all other solutions. An equal amount of borax added 
to it makes it more soluble. It is sometimes used in the 
form of an ointment (10 per cent), and is valuable in the 

s (65) 



66 



EYE NURSING. 



various inflammations of the conjunctiva and cornea. In 
solution it is often used as a vehicle for eye drops and in the 
preparation of surgical dressings which are dipped into it 
and then dried. 

Carbolic Acid.- — This is used in very weak solutions 
(% per cent.), as it is irritating to the eye when first 
applied. It is used chiefly for cleansing the eye and for its 
antiseptic properties in septic cases. The pure phenol, and 
not the commercial form, should be used in making the 
solution, as it is less irritating. Carbolic acid may be ap- 
plied in the form of an ointment (2 to 5 grains to the 
ounce) to rub between the inflamed lids of the eye. In a 
strength of 1 to 20, the solution is often used for disinfect- 
ing instruments by immersing the instruments in it for five 
or ten minutes. 

Mercuric bichloride is one of the best antiseptics we 
have. It has a limited use about the eye, however, as it is 
highly irritating when used in sufficient strength to be 
germicidal in action. It has the further disadvantage of 
being a poison and of coagulating the albumin in the -tissue, 
thus limiting its action to the surface of the tissue. For 
cleansing and irrigating the eye, it is used in solution of 
1 to 10,000 and 1 to 5000, but never stronger than 1 to 
3000. In the latter strength it is highly irritating. When 
cocaine is dropped into the eye, as for cataract operation, 
and then the eye irrigated even with 1 to 5000 bichloride 
of mercury solution, haziness of the cornea is produced and 
permanent opacities may result. The solution is not to be 
recommended in such cases. Simple sterilized water or 
boracic acid solution is much to be preferred. In the form 
of an ointment, 1 to 5000 (vaseline as a base), bichloride is 
often used for its antiseptic properties. In the treatment 
of trachoma a solution of 1 to 500 or even 1 to 250 is at 



ANTISEPTICS. 



67 



times applied on the everted lids. It should be strictly 
limited to the lid, however, and no excess allowed to run on 
the eyeball. For disinfecting the hands a solution of 1 to 
1000 may be used, the hands being immersed for two or 
three minutes in the solution. On account of its corrosive 
action it is never used on instruments. Surgical dressings 
of gauze, dipped into a solution 1 to 5000 or 1 to 3000 of 
bichloride of mercury, then dried and prepared, are some- 
times used about the eye. As a rule, however, simple 
sterilized dressings are the best for the eye. 

Biniodide of mercury, in very weak solution, is some- 
times used for irrigating and cleansing the eye. The late 
Professor Panas used a solution of 1 part of biniodide of 
mercury, 4 parts of alcohol, and 20,000 parts of water for 
cleansing the eyes before operating. Its efficiency in such 
weak solution has been doubted and its chemical com- 
patibility questioned, since what little mercury is present 
is precipitated, it is claimed. 

Oxycyanide of mercury, in solution of 1 to 500 or 1 to 
1000, has decided antiseptic properties and is less irritating 
to the eye than the bichloride of mercury. It has the fur- 
ther advantage of not injuring instruments when they are 
dipped into it. 

Calomel, dusted into the eye, acts as an irritant and 
antiseptic, probably by being changed into the bichloride of 
mercury by the action of the salt tears. 

Potassium permanganate, in solution of 1 to 500 to 
1 to 100, is a strongly antiseptic agent of a purplish hue, 
which is somewhat irritating to the eye when used in strong 
solution. On account of its staining properties it is more 
or less objectionable. 

Formalin contains about 35 per cent, of formic alde- 
hyde. In solution of 1 to 5000 to 1 to 2000 it is astringent, 



68 



EYE NUKSING. 



irritant, and strongly antiseptic in action. It has highly 
preservative properties. In the weaker solution it is used 
to cleanse and disinfect the eye before operations, but should 
not be used in those cases where the eye is to lie opened, as 
in cataract operations, as it is too irritating and causes too 
much congestion of the parts. In the stronger solutions, 
1 to 2000, it is used as a cleansing solution and as an ap- 
plication to the lids of the eye in the contagious inflamma- 
tory diseases. 

Formaldehyde, in solution 1 to 3000 to 1 to 1000, is 
strongly antiseptic, but very irritating to the mucous mem- 
branes, and for that reason is seldom used about the eye. 

Chlorine water, the official, which contains % 0 of 1 
per cent, of chlorine gas, is astringent and antiseptic in 
action, and where used in dilution of 3 drachms to the pint 
of water is but slightly irritating to the eye. It is used for 
cleansing the eye before operations and also in the acute 
contagious inflammatory diseases. The solution rapidly 
deteriorates, and for that reason must be freshly prepared 
and kept away from the light in a dark-colored, glass- 
stoppered bottle. 

Hydrogen peroxide, in 3 per cent, solution (the usual 
strength as it comes in the original bottle), is a strong anti- 
septic, being both germicidal and disinfectant in its action. 
It may be used in full strength, or, if too irritating, may 
be diluted one-half, when it may be used freely in the eye, 
provided there is no ulceration of the cornea, when it should 
be used with great caution and its action limited to the lids 
by being applied with probe and cotton. For removing the 
membrane from the lids that follows the operation of "ex- 
pression" for trachoma, and for cleansing and disinfecting 
the eye occasionally in purulent inflammation of the con- 
junctiva, it is an excellent preparation. It should not be 



ANTISEPTICS. 



69 



used too frequently, however, for cleansing the eye, as it 
becomes an irritant. When it comes in contact with pus or 
blood it breaks up the corpuscles through oxidation and 
causes a froth or foam. This foam should always be washed 
away with boracic acid solution or plain, sterilized water. 
As the solution quickly deteriorates it should be kept in a 
glass-stoppered bottle and in a cool place. 

The preparation known as pyrozone (3 per cent, solu- 
tion) is less acid than some other preparations of peroxide 
of hydrogen on the market, and for that reason is recom- 
mended in the eye, as it is less irritating than the others. 

Pyoktanin, (pus-killer), or methyl violet, in solution 
of 1 to 5000 to 1 to 2000, is antiseptic and unirritating in 
action. On account of its staining properties it has never 
had wide use. Stilling recommended it a few years ago, 
and it has been used in purulent conditions of the conjunc- 
tiva for cleaning and disinfecting, but its use is almost 
wholly given up now. 

Iodoform is but slightly antiseptic in its action. It is 
highly offensive in odor. It and its substitutes, aristol, 
iodol, etc. (which latter have not the offensive odor of the 
former) , are used chiefly in dressing wounds. They may be 
dusted on the wound or applied in the form of an ointment 
(10 per cent.). Corneal ulcers requiring stimulation are 
sometimes dusted over with iodoform with benefit. Gauze 
impregnated with iodoform (10 per cent.) is much used 
as a dressing for wounds. 

Zinc chloride, in weak solution (1 to 1000 to 1 to 300), 
is antiseptic, astringent, and stimulating in its action. It is 
seldom used for irrigation of the conjunctiva because of its 
irritating properties. In % to 1 per cent, solution it is 
frequently used as an application to the lids in chronic in- 
flammation. 



70 



EYE NURSING. 



Lysol is a tar-oil dissolved in fat and then saponified 
with alcohol. It is antiseptic, disinfectant, and deodorant 
in action. In a 1 to 2 per cent, solution it is excellent for 
cleansing the field of operation, hands, and instruments. 

Chinosol, in solution of 1 to 3000 to 1 to 2000, is 
mildly antiseptic in action, and is used for cleansing the 
conjunctiva. 

ASTRINGENTS. 

Many of the antiseptics are also astringent in action. 
This class of remedies contracts the blood-vessels and tis- 
sues (especially mucous surfaces) when brought in contact 
with them. In this way the blood supply to the part is 
lessened and the secretions from mucous membranes 
diminished, partly by depleting the tissue of blood and 
partly by coagulating the albumin in the tissue. 

Silver Nitrate. — Of all the astringents used about the 
eye, nitrate of silver is the most efficient and the one most 
commonly employed. It is not only strongly astringent, 
but when used in strong solution or in solid form acts as a 
caustic. It is also a valuable antiseptic and germicide, and 
is often employed in the acute contagious diseases of the 
eye. Acting in its double capacity of astringent and germi- 
cide, it is the most valuable remedy we have in such affec- 
tions. Solutions of the drug are soon decomposed and ren- 
dered inert when left exposed to light; hence they should 
be kept in dark-colored bottles, and, when not in use, in a 
dark place. The strength of the solutions used varies from 
5 to 20 grains to the ounce, exceptionally 40 to 60 grains 
to the ounce, for astringent and antiseptic purposes. Solu- 
tions stronger than this are used for their caustic action. 
When brought in contact with mucous surfaces silver nitrate 
coagulates albumin and forms an insoluble precipitate 
which renders its action superficial. For this reason it 



ASTRINGENTS. 



71 



must be reapplied to the conjunctiva, in the acute microbic 
diseases of that membrane, especially in gonorrheal 
ophthalmia, every twenty-four to forty-eight hours, accord- 
ing to the severity of the reaction, in order to kill the fresh 
supply of micro-organisms which appear on the surface 
from the deeper tissues. Solutions of nitrate of silver of 
5 to 10 grains to the ounce may be dropped into the eye 
without harm, unless there is ulceration of the cornea. 
Where there is ulceration of the cornea a precipitate of 
silver may form an opacity at the site of the ulcer. Crede's 
method of preventing ophthalmia neonatorum in the lying- 
in hospital at Leipzig was tadrop 1 or 2 drops of a 10-grain 
to the ounce solution of silver nitrate into the eyes of all 
infants immediately after birth. In this way he reduced 
the percentage of such cases enormously. In solution 
stronger than 10 grains to the ounce silver nitrate should 
always be applied to the everted lids by means of cotton on 
a probe, and the excess immediately washed away with a 
salt water solution. In stick form, or strong solution, silver 
nitrate is used to remove granulation tissue, polypi at the 
base of ulcers on the lids, etc. It may be fused with other 
drugs, as nitrate of potassium, and used as a caustic. The 
solutions of silver nitrate when used for too long a time on 
the conjunctiva cause it to turn to a slate color (argyria). 
This point should be borne in mind. 

Silver Substitutes. — Various substitutes for silver ni- 
trate have been tried in the last few years. They contain 
a certain percentage of silver nitrate, are organic in com- 
position, but little irritating, and do not coagulate albumin, 
and for this latter reason are supposed to penetrate deeper 
into the tissues. They are germicidal and astringent in 
their action also. The most valuable one of these prepara- 
tions and the one containing the largest percentage of silver 



72 



EYE NUKSING. 



(30 per cent.) is argyrol (silver vitellin, Barnes & Hille). 
It is especially useful in the acute contagious diseases of 
the conjunctiva, and is used in solution varying from 25 
to 250 grains to the ounce. Protargol contains about 8 per 
cent, of silver, is more irritating than argyrol, and is used 
for the same purpose, in solutions varying in strength 
from 5 to 30 grains to the ounce. Argentamine contains 
about 10 per cent, of silver, and is a slightly irritating as- 
tringent, and antimicrobic in action. It may be used in a 
5- to 25- grain to the ounce solution. Argonin may be used 
in solution of from 5 to 30 grains to the ounce, and in the 
same cases as argentamine. AMol (lactate of silver) and 
coJhrgol (argentum colloidale, Crede) are used in solutions 
for disinfecting the conjunctiva. Itrol (citrate of silver) 
is used in the form of a dusting powder for infected wounds 
and in the contagious diseases of the eye. It is non-irri- 
tating and is to be applied from an insufflator, so as to 
drive the substance into the affected tissues (Meyer). 

Alum. — The sulphate of alum in crystal form,' shaped 
into a pencil or stick, is frequently used in the milder in- 
flammations of the lids. It acts as an astringent and ex- 
siccant and coagulates albumin. At times it is used in solu- 
tion ( 1 per cent., as alum curd) in relaxed conditions of th? 
conjunctiva. 

Alumnol, a preparation of aluminum (naphthol disul- 
phonate), is mildly astringent and sedative in action; most 
commonly it is used in powder form, 1 part of alumnol to 
5 or 10 parts of boracic acid, bismuth, or talcum, to dust 
over wounds. It is soluble in water and may be used in 
solution (5 per cent.) for irrigation. 

Acetic acid, in solution (3 per cent.), acts as a mild 
astringent and sedative and is occasionally used in mild in- 
flammations of the conjunctiva. In case of lime burn of 



ASTRINGENTS. 



73 



the eye, especially when seen early, it is most useful, acting 
as a chemical antidote. Weak solutions of vinegar may be 
used for the same purpose. 

Tannic acid, in solution (1 to 20 per cent.), is mark- 
edly astringent and tonic in action on mucous membranes, 
is slightly irritant in weak solution, moderately so in strong- 
solution, and coagulates albumin. It is one of the most 
frequently used drugs in inflammatory conditions of the 
conjunctiva. It is often used in the form of the aqueous 
solution (Agnew) : — 

R Acidi tannici, 

Sodii biborati aa gr. x. 

Glycerini 5j. 

Aquae camph 

M. et ft. sol. 

Sig. : Two drops in each eye three times a day. 

This solution is extensively prescribed at the Manhat- 
tan Eye and Ear Hospital, New York. In the treatment 
of trachoma, in which it is very beneficial, tannic acid may 
be used in from 2 to 8 per cent, solution of camphor 
water, to which 1 drachm of glycerin is added. The old 
preparation of glycerol e of tannin (120 grains of tannin to 
1 ounce of glycerin) is rarely used now, as tannin is much 
more irritating in pure glycerin as a vehicle than when 
mixed with camphor water. 

Zinc svlphate, in solution (1 to 2 per cent.), acts as 
an astringent. In the stronger solutions it is applied to the 
conjunctiva with probe and cotton. If dropped into the 
eye it should not be stronger than 1 to 3 grains to the ounce 
of water. The strong solutions act as mild caustics. 

Zinc oxide is used most frequently in an ointment (20 
per cent.) with benzoinate of lard as a base. It is mildly 
astringent and sedative in action. The dry powder is some- 



74 



EYE NURSING. 



times used in place of the ointment. Oxide of zinc is used 
chiefly in eczematous conditions of the lids, being both 
soothing and protective in action. 

Copper sulphate, in weak solution ( y 5 to % P er cen ^- ) > 
may be used as a stimulating tonic in chronic inflammation 
of the conjunctiva, as in trachoma. 

Lead subacetate (liquor plumbi subacetatis) acts as a 
mild astringent and sedative; in a weak aqueous solution 
it was formerly used frequently as a wash ( 1 to 2 per cent. ) 
for the eyes, but, on account of its causing dense white 
opacities on the cornea when the least abrasion or ulcer on 
that membrane was present, its use has been almost entirely 
abandoned, and wisely so. 

Suprarenal extract and its derivatives act as pure as- 
tringents and hemostatics, with but little irritation or re- 
action following. They are all used in solution, and where 
dropped into the eye cause marked blanching of the mucous 
surface in from one to two minutes' time. This lasts from 
one to two hours and is not followed by hyperemia, unless 
used in excess and for a long period of time. The extract 
itself is but little used now; its alkaloids, which are more 
stable and more convenient for use, have displaced it. 

Adrenalin chloride, in solution (1 to 1000 to 1 to 
5000), is the widest used of all the derivatives. 

Hemostatin solution (1 to 1000), suprarenin solution 
(1 to 1000), and suprarenatin (1 to 1000) are all of a 
similar nature to, and act like, adrenalin. As remedies for 
the cure of disease these drugs are of but little value. They 
markedly increase the effect of cocaine, however, and are 
very useful in operations on the eye to prevent the flow of 
blood. They should not be combined in solution with 
cocaine or atropine, but each drug dropped into the eye 



IRRITANTS. 



75 



separately. When combined in solution with cocaine it 
seems to cause irritation of the eye. 

ANODYNES. 

Cocaine, holocaine, eucaine, and all of the local anes- 
thetics are anodynes; but these will be described under 
anesthetics. 

Heat and cold also are, in the true sense of the word, 
anodynes, and the method of their application may be found 
under their proper headings (pages 103 and 105). 

Tincture of opium as a local application has been and 
is still used for its anodyne and sedative effect. It has been 
largely replaced, however, by the simple cold and hot ap- 
plications and the local anesthetics. Poultices of various 
substances were once much used for their anodyne and seda- 
tive effect on the eye, but they, too, have been almost wholly 
abandoned by the profession, and fortunately so, for, while 
soothing at first, their ultimate effect was often fatal to the 
sight of the eye. 

Irritants. 

Such remedies cause a moderate amount of inflamma- 
tion, and are used to promote absorption and to stimulate 
indolent ulcers, etc. The mercury preparations furnish the 
greatest number of irritants used in the eyes. 

Yellow oxide of mercury (hydrargyri oxidum flavum) 
in the form of a salve or ointment (Pagenstecher's), vary- 
ing in strength from 1 to 3 per cent., according to the effect 
desired, is the most valuable of all these preparations. 
Some eyes are much more susceptible to its action than 
others, and it may have to be reduced to % or % per cent, 
before it is tolerated. Furthermore, unless prepared with 
the greatest care, the mercury being reduced to an impal- 



76 



EYE NURSING. 



pable powder, or, better, precipitated from solution, before 
being added to the base (which may be vaseline and lanolin 
or benzoinated lard) it causes too much irritation, and does 
actual harm rather than good. This yellow ointment 
to 1 per cent.) is a specific in blepharitis marginalis and in 
phlyctenular keratitis and conjunctivitis. In 3 per cent, 
strength it is valuable as a stimulant and irritant in chronio 
and indolent ulcers of the cornea, as in pannus. In mollus- 
cum contagiosum it often effects a cure in a few days, if 
well rubbed into the diseased spots. 

Ammoniated mercury (white precipitate), in the same 
strength ointment as the yellow oxide, is often used in 
blepharitis and phlyctenular keratitis, when the yellow oxide 
proves too irritating. 

Red oxide of mercury, in the form of an ointment (1 
to 2 per cent.), is highly irritating to the eye and is but 
seldom used. 

Mild chloride of mercury (calomel), in powdered form, 
is often dusted into the eye for its stimulating effect where 
there is superficial and indolent inflammation of the cornea. 
The tears are supposed to convert part of it into the strong 
bichloride of mercury, and it is to the latter that the stimu- 
lation is chiefly due ; through part of it may be due to the 
mechanical irritation of the powder rubbing on the eye. 

Bichloride of mercury, in solution (1 to 2000 to 1 to 
3000), may be used in similar conditions as those where 
calomel is used for an irritant. It is not so desirable, how- 
ever, as it does not remain in the eye so long as the calomel. 

Sulphate of copper, in the form of a crystal, pure, or 
mixed with equal parts of alum and nitrate of potassium 
(lapis divinus), mounted in a wood holder for convenient 
use, is one of the most frequently used stimulating irritants 
used in ophthalmic practice. In chronic inflammation of 



COUNTER-IRRITANTS. 



77 



the eyelids (trachoma) it is the sheet anchor when opera- 
tive procedure is not resorted to. 

Sulphate of zinc, in solution (2 to 3 per cent.), is 
sometimes used as an irritant. 

Tincture of opium, once much used as a stimulant and 
irritant m the eye, has been given up almost entirely. Its 
action was due to the alcohol contained in the solution. 

Counter-irritants. 

These are substances used to produce a violent inflam- 
mation at some distance from the eye. Their use is indi- 
cated only in the deep-seated and chronic inflammations of 
the eye accompanied with severe pain. The temple and the 
back of the ear over the mastoid region are the points usu- 
ally selected for counter-irritation. 

Canikarides, in plaster, cut to the desired size, may be 
placed on the temple or back of the ear and allowed to re- 
main till a blister is raised, when it is removed, the blister 
punctured and dressed with vaseline ; or, if continued effect 
is,desired, it may be kept open with a stimulating ointment, 
as resorcin. Cantharides collodion may be painted on the 
temple or back of the ear and the same effect secured as 
when the plaster is used. 

Tincture of iodine may be painted on the temple or 
back of the ear, where a mild counter-irritant is desired. 
The nurse should be careful to protect the eye when paint- 
ing the temple with iodine or cantharides collodion. 

Setons, issues, etc., are no longer used as counter-irri- 
tants in ocular affections, as they are too severe. Other 
means more pleasant and more efficacious may be em- 
ployed. 



78 



EYE NURSING. 



Caustics. 

These are substances, used to destroy diseased tissues. 

Silver nitrate, "mitigated/' that is, mixed with nitrate 
of potash, in stick form, is much used. Copper sulphate, 
zinc sulphate, and alum, in solid stick form are all used as 
mild caustics. Bichloride of mercury in concentrated solu- 
tion (1 to 250) may be used with an applicator and cotton 
for the same purpose. 

Carbolic acid (phenol), 95 per cent, pure, applied to 
infective ulcers is most effective. After the eye is cocain- 
ized and the surface of the ulcer dried with cotton on an 
applicator, the base of the ulcer should be touched with the 
tip of a probe or a wooden tooth-pick which has been dip- 
ped into the pure carbolic acid, taking care that no excess 
of the acid runs into the healthy tissue. A weak solution of 
alcohol should be at hand to neutralize any such excess. 
This may be applied by means of a small piece of cotton 
wrapped on a probe. 

Tincture of iodine, 3 to 5 per cent, solution, may be 
used in the same manner as the carbolic acid, and is a 
most valuable agent. 

Actual Cautery. — This may be applied by heating a 
probe in a spirit flame and the diseased tissue burned, or 
the galvanocautery or Paquelin's cautery may be used. The 
actual cautery is used chiefly to check the progress of in- 
fected ulcers and to destroy diseased tissue. 

Mydriatics. 

These are drugs which dilate the pupil, and the ma- 
jority of them at the same time paralyze the ciliary or 
focusing muscle, thereby suspending the accommodation. 
Their action is local, that is, when dropped into the eye, 



MYDRIATICS. 



79 



they act directly on the iris and ciliary muscles, and their 
action is confined to the eye in which they are dropped. 
If used in excess, and especially if allowed to drain into the 
nose through the tear ducts, or to run down the face into 
the mouth (as may happen when putting drops into the 
eyes of a struggling child), symptoms of poisoning may 
develop. A secondary effect, an elevation of tension, or 
slight hardening of the eye, is sometimes noticed after the 
use of mydriatics. This is due to the dilatation of the 
pupil and crowding the iris against the canal of Schlemm, 
partly closing it, thus preventing a free exit to the natural 
secretions of the eye. On this account mydriatics are never 
to be used in glaucoma. 

.4 fro pine sulphate is the most widely used of this class 
of remedies. It is the active principle (alkaloid) of bella- 
donna, and its salts are used in solutions of from 1 to 15 
grains to the ounce. The usual strength is 4 grains to the 
ounce in adults. In special instances, as for breaking adhe- 
sions between the iris and the lens capsule, a 15-grain to 
the. ounce solution may be used, but with caution, as poison- 
ous, or "toxic," effects may be caused. The symptoms of 
atropine poisoning consist in dryness of the throat, diffi- 
culty in swallowing, redness and swelling of the conjunc- 
tiva and even of the lids, widely dilated pupils, flushed and 
burning skin, rapid pulse, dizziness, and, in extreme cases, 
delirium and convulsions. Death may ensue through paral- 
ysis of respiration and coma. This poisonous train of 
symptoms may be due to an idiosyncrasy of the patient for 
the drug, 1 drop sometimes being sufficient to cause both 
local and general symptoms of poisoning. Or poisoning 
may be caused by the careless use of the drug, allowing it 
to run over the cheeks into the mouth of the patient, or by 
not holding the fingers over the puncta at the inner angle 



80 



EYE NURSING. 



of the lids, allowing an excess of the drug to go into the 
nose, where it is rapidly absorbed. Hence the" precautions 
necessary in the use of this drug. 

When a solution of atropine (4 grains to the ounce) is 
dropped into the eye the pupil is first affected, beginning to 
dilate in ten or fifteen minutes and is widely dilated in 
thirty to forty minutes. The ciliary muscle is not affected 
so quickly, and the accommodation is not suspended for an 
hour or two. In fact, for complete suspension of the ac- 
commodation it is necessary to instill 1 drop of the solu- 
tion every five minutes for the space of thirty minutes, then 
wait for from one to two hours, when the paralysis is com- 
plete. Atropine is used in this way (coup sur coup) to 
tear away adhesions of the iris from the lens capsule, or to 
dilate the pupil and relax the ciliary muscle in acute iritis. 
Usually atropine is instilled but two or three times during 
the twenty-four hours after the eye is well under the in- 
fluence of it. It requires about from ten days to two weeks 
to recover from its effect and sometimes longer. 

For its quieting effect, by placing the ciliary muscle at 
rest, in a splint, as it were, atropine is used in many inflam- 
matory conditions of the eye. In iritis it answers a double 
purpose: first, to dilate the pupil and prevent adhesions 
(synechiie), or to break up the adhesions if they exist; sec- 
ondly, to place the ciliary muscle at rest and relieve pain. 

In ulceration of the cornea, and in the deep-seated in- 
flammations of the eye, as well as in injuries, atropine is 
used for its quieting and sedative effect. It is contra-indi- 
cated in glaucoma, and should be used with great care in 
all aged people, as it sometimes induces glaucoma. In in- 
flammations limited to the conjunctiva and lids it is also 
contra-indicated. As a cycloplegic, to place the ciliary mus- 
cle at rest, in order to adjust glasses to the eye, it has had 



MYDRIATICS. 



81 



extensive use, but is used less and less for this purpose since 
the introduction of instruments of precision, rendering its 
employment unnecessary for this purpose, except in chil- 
dren and where spasm of the ciliary muscle is present. 

Scopolamine hydrobromate is the active principle of 
Scopolia atropoidea and is much more powerful in its 
action than atropine. It is used in solutions of from % 
to 1 grain to the ounce (Y w to % per cent.) and in exactly 
the same way as atropine is used. Its action is much 
quicker than that of atropine, and its effect wears off 
sooner. One drop instilled at intervals of five minutes for 
one-half hour (1 grain to 1 ounce in adults and half to 
one-fourth this strength in children) places the ciliary 
muscle completely at rest in one hour's time from the be- 
ginning of the instillations. The effect wears off in from 
three to four days' time. On account of its rapid and 
powerful action, and the earlier disappearance of the effect, 
it is used in preference to atropine for the adjustment of 
glasses. The tension of the eye is believed not to be in- 
creased by its use, as is the case with atropine, making it 
safer for use in elderly people. Great care must be ex- 
ercised in its use, as any excess flowing into the nose or 
mouth quickly produces alarming toxic effects. 

Hyoscine hydrobromate and hydrochloride, which- are 
isomeric with atropine, but much more poisonous, are some- 
times used in solutions of from y 2 to 2 grains to the ounce, 
in the same conditions in which atropine is indicated. On 
account of its poisonous effects it is rarely used, and then 
usually when atropine cannot be employed. 

Hyoscyamine, the active principle of Hyoscyamus 
niger, is used in solution of from 2 to 4 grains to the ounce. 
When instilled into the eye it dilates the pupil widely in ten 
minutes, which continues thus for from thirty-five to forty 

6 



82 



EYE NURSING. 



hours, and does not return to normal for eight or ten days. 
It paralyzes the focusing muscle in about two hours' time. 

Duboisin sulphate and liydrocldorate, the active prin- 
ciples of Duboisia myoporoidea, act in the same manner as 
atropine, but more powerfully, and the effects wear off 
sooner — in five or six days' time. They are used in place 
of atropine when there is an idiosyncrasy for the latter. 
From 2 to 4 grains to the ounce solution is the proper 
strength. 

Daturin, the active principle of stramonium, in solu- 
tion of from 2 to 4 grains to the ounce, acts very much like 
duboisin and is used under similar conditions. 

Euphthalniin liydrocldorate, in 5 per cent, solution, is 
used for dilating the pupil for diagnostic purposes solely, 
since it has but little effect on the ciliary muscle. A few 
drops instilled into the eye causes a maximum dilatation of 
the pupil in from sixty to ninety minutes, which state is 
maintained for two or three hours ; the pupil gradually re- 
turns to the normal size in about twenty hours' time. 

Homatropin liydrobr ornate, a synthetic preparation, is 
often used in solution (2 per cent.) to dilate the pupil for 
diagnostic purposes. The pupil begins to dilate in from 
eight to ten minutes after the first instillation, and with 
six instillations, at five-minute intervals, the pupil is widely 
dilated in from one to one and one-half hours' time, return- 
ing to the normal in twenty-four to forty-eight hours' time. 
In 4 per cent, solution it is used as a cycloplegic as an aid 
in adjusting glasses, 1 drop being instilled every five min- 
utes for thirty minutes, then waiting one hour before the 
test for glasses is begun. It is not reliable for this purpose, 
however. 

Ephedrin and mydrin are other mydriatics used much 
in the same way and for the same purposes as the weaker 



MYOTICS. 



83 



solutions of homatropin. They have but little effect on the 
ciliary muscle. Ephedrin is used in 2 per cent, solution and 
mydrin in 10 per cent, solution. 

Cocaine hydrochlorate, in from 2 to 4 per cent, solu- 
tion, is often used as a mydriatic for diagnostic purposes, 
its effect on the ciliary muscle being but slight. Its action 
as a mydriatic is brought about by contraction of the blood- 
vessels of the iris, lessening the volume of that membrane, 
and perhaps by stimulation of the dilator fibers supposed 
to exist in the iris. In this respect it differs from the 
action of atropine, which paralyzes the circular muscle 
fibers of the iris. Two or 3 drops of a 4 per cent, solution 
dropped into the eyes cause the pupil to dilate in four or 
five minutes, reaching the highest effect in from fifteen to 
twenty-five minutes, and gradually passing off in from four 
to eight hours. When used in conjunction with atropine 
it is found to increase the effect of the atropine paralysis, 
as shown by the pupil becoming wider if atropine is first 
used until it produces its fullest effect, and then the cocaine 
instilled into the eye. This undoubtedly is caused by con- 
stricting the blood-vessels and lessening the volume of the 
iris, so that it can be crowded still farther into the iris 
angle. 

Myotics. 

These are remedies employed for contracting the 
pupils. They are also used to reduce the tension of the eye, 
as in glaucoma, or in threatened perforation of a corneal 
ulcer, especially if the ulcer is at the margin of the cornea, 
to lessen the danger of perforation and of prolapse of the 
iris into the corneal wound should the ulcer perforate; in 
serous iritis (cyclitis of Fuchs) ; and at times to counteract 
the effect of mydriatics. 



84 



EYE NURSING. 



Eserin sulphate and salicylate (physostigmine), in 
solution of from 1 to 2 grains to the ounce (% to % per 
cent.), when dropped into the eye causes the pupil to con- 
tract in from four to five minutes, and the ciliary muscle is 
stimulated to action at the same time. The full effect of 
the drug on the iris and ciliary muscle is attained in about 
one-half hour. The effect on the ciliary muscle wears off in 
about two hours, while the pupil may not return to the nor- 
mal size for from twelve to forty-eight hours. Eserin has 
no effect on a pupil widely dilated with atropine, but con- 
tracts to a slight extent a pupil dilated from paralysis of 
the third nerve. Eserin when used in strong solution (4 
to 5 grains to the ounce), as is often done to obtain quick 
results, e.g., in glaucoma, may cause marked circumcorneal 
injection, spasm of the ciliary muscle, a feeling of tension, 
and a dragging pain in the eye, with at times neuralgic 
pains in the temple. It is said to be less irritating when 
Tised in oily solution. When eserin is to be used for a con- 
siderable time the solutions must be quite weak, from % to 
1 grain to the ounce ; and, when the weak solutions are not 
tolerated, pilocarpine is used instead of it. If there is any 
tendency to iritic inflammation, pilocarpine should be used 
from the first. Eserin finds its chief use to reduce the ten- 
sion in glaucoma, and, at times, in ulcerative keratitis, espe- 
cially where there is tendency to perforation and atropine 
has not proved beneficial, it may be used with benefit. The 
solution should be kept in a colored bottle and in a dark 
place ; after exposure to light for some time the clear solu- 
tion changes to a red one. The efficiency of its action is but 
little affected, however, by this change in color. 

Pilocarpine hydrocldorate, the active principle of jabo- 
randi, is used in solutions of from 1 to 2 per cent. Its 
action on the iris and ciliary muscle is not as strong as that 



ANESTHETICS. 



85 



of eserin, but it has the great advantage of not irritating 
the eye as does the eserin solutions. Where eserin is not 
tolerated, and for prolonged use, as in chronic, non-inflam- 
matory glaucoma, for reducing the tension, it is very useful 
in solutions of from 4 to 8 grains to the ounce. In de- 
tachment of the retina, choroiditis, rheumatic paralysis, and 
tobacco amblyopia the drug is often used hypodermically 
( Vio to % grain) to produce sweating. Great care must be 
exercised in giving hypodermic injections of pilocarpine 
that the solution be sterile, the syringe absolutely clean, 
and the injection given deeply into the muscle of the arm 
or leg; as abscesses are prone to follow its use. 

Anesthetics. 
The local anesthetics most commonly used in the eye 
are: cocaine, holocaine, and eucaine. They produce anes- 
thesia by paralyzing the sensory nerve-fibers with which 
they come in contact; hence their action is strictly a local 
one. 

Cocaine muriate is the active principle of Erythroxylon 
coca, and is used in solution, as a rule, 2 to 8 per cent., 
though it may be used in the crystal or powdered forms 
when intense and quick effect is desired. Its anesthetic 
properties were discovered by Koller (1884). It is largely 
employed as a local anesthetic for most operations upon the 
eye and its appendages, even enucleation of the eyeball hav- 
ing been performed under cocaine anesthesia. As a rule, 
however, enucleation of the eyeball, or evisceration, and the 
graver plastic operations about the eye should be performed 
with the patient under the influence of a general anesthetic. 
When a few drops of a 4 per cent, solution of cocaine is 
dropped into the eye it first causes slight irritation, blanch- 
ing the conjunctiva in from two to five minutes, constrict- 



86 



EYE NURSING. 



inff the blood-vessels, loss of sensation in the cornea and 
conjunctiva beginning at the same time and reaching its 
greatest effect in from six to eight minutes. If the instilla- 
tions are repeated three or four times at three-minute inter- 
vals, in from ten to twelve minutes from the time of the 
first instillation, the anesthesia becomes sufficiently com- 
plete for operations on the eyeball. The pupil is moder- 
ately dilated and the palpebral fissure made wider, both 
brought about through stimulation of the sympathetic 
nerves to these structures (Fuchs). If the instillations of 
cocaine are continued too long and too frequently, especially 
when used in strong solutions, the corneal epithelium is 
peeled off, an effect which is not desired. Oily solutions 
(y 2 to 1 per cent.) of the drug are sometimes used in cor- 
neal affections. Adrenalin chloride solution used in con- 
junction with cocaine seems to increase the anesthetic 
action of the cocaine. The anesthetic effect of cocaine dis- 
appears in from twenty to thirty minutes, but the pupil 
may remain dilated for as many hours. The accommoda- 
tion is but mildly affected, being slightly suspended. 
Toxic effects may result from the too free use of cocaine, 
especially if allowed to drain into the nose or mouth. They 
are : dizziness ; f aintness ; very rapid, feeble, and irregular 
pulse ; rapid and irregular respiration, and at times delir- 
ium. The patient, under such circumstances, should be 
laid flat and stimulants applied : whisky, strychnine, etc. 

Holocaine hydroclilorate, a synthetic preparation, is a 
more powerful local anesthetic than cocaine, and in less 
concentrated solution, a 1 per cent solution equaling a 5 
per cent, solution of cocaine in anesthetic effect. The solu- 
tion has antiseptic properties, kills pus-organisms, and 
acts as a protoplasmic poison, checking fomentation and 
putrefaction. When dropped into the eye, a 1 per cent. 



MISCELLANEOUS REMEDIES. 



87 



solution causes smarting for a few seconds, anesthesia be- 
ginning in from three to five minutes and continuing for 
fifteen or twenty minutes. Eepeated in five minutes, oper- 
ations may be commenced in ten minutes after the first 
instillation. The drug is more penetrating than cocaine 
and is very desirable when the iris is to be cut. It allows 
freer bleeding, however, than when cocaine is used, as it 
does not contract the blood-vessels. It does not peel the 
corneal epithelium as does cocaine, and is said not to in- 
crease the tension of the eye. The pupil and ciliary muscle 
are affected but very slightly by way of dilatation of the 
former and suspension of action in the latter. On account 
of its toxic effect when injected hypodermically it is rarely 
used in that manner. 

Eucaine hydro chlorate is a synthetic preparation, and 
conies in two forms : eucaine A and eucaine B. The latter 
only is used in ophthalmic practice, as the former proves 
to be too irritating to the eye. Eucaine B is used in 2 per 
cent, solutions, and, when instilled into the eye, anesthesia 
begins in two or three minutes, continues for eight or ten 
minutes, and totally disappears in from fifteen to twenty- 
five minutes. It does not dilate the pupil, affect the ciliary 
muscle, or blanch the conjunctiva. It is not as effective an 
anesthetic as either cocaine or holocaine, and for that 
reason is not extensively used for operations on the eye. 

Miscellaneous Remedies. 
Jequirity is a preparation first introduced into oph- 
thalmic practice by de Wecker for the treatment of chronic 
trachoma complicated with pannus, that is, where the cor- 
nea is covered with blood-vessels and opaque epithelium. It 
may be used in the form of an infusion, as recommended by 
de Wecker; or, better yet, in the form of a powder, as 



88 



EYE NURSING. 



recommended by Cheatham. The infusion is made by 
macerating 3 to 5 per cent, of the powdered bean in cold 
water for six or eight hours, and is applied to the everted 
lids with cotton on an applicator once every twenty-four 
hours, until a violent inflammation is started. Simply 
dusting the powdered bean over the front of the eye and 
on the everted lids, as first recommended by Cheatham, of 
Louisville, is much the better method of application. 
Within from twelve to twenty-four hours after the powder 
is dusted into the eye, a violent inflammation, accompanied 
by marked swelling of the lids, heat, burning, and intense 
pain, is incited. To control the swelling and relieve the 
pain the nurse must apply iced cloths frequently, just as 
in a case of gonorrheal ophthalmia. In from forty-eight to 
seventy-two hours a membrane is formed on the lids and 
the cornea, which must be gently washed and rubbed off 
as it separates from the underlying tissue. In fact, it is 
to be treated as a croupous or membranous conjunctivitis, 
which it is, in effect. At the end of a week's time the vio- 
lent inflammation rapidly subsides, but the clearing away of 
the blood-vessels and opaque epithelium through inflamma- 
tory reaction may continue for weeks ; consequently the 
drug should not be reapplied within four weeks after the 
first application. Jequirity is contra-indicated unless there 
is pannus covering the cornea. I have seen some most ex- 
cellent results from the use of this drug, in fact, useful 
vision restored, in old trachoma cases with pannus where 
sight had been reduced to counting fingers. Owing to the 
violent inflammation which it produces when dusted into 
the eye, these cases should be taken into the hospital and 
treated as house cases, and should not be treated as outdoor 
cases, since there is danger of destroying the eye if it is 
not properly cared for. I have used the drug often and 



MISCELLANEOUS REMEDIES. 



89 



have seen it used in many cases and have never had any bad 
results from its use. It is where the cases are not properly 
cared for after the drug is used that the greatest danger lies. 

Fluorescin is a coal-tar derivative, a staining fluid (2 
per cent, solution), used for diagnostic purposes only. 
When dropped into the eye it stains any ulcerated spot of 
the cornea a greenish hue, thus indicating the position and 
extent of an ulcer or abrasion. A drop of cocaine used just 
before the fluorescin is instilled increases the effect of the 
latter. 

/Esorcin, also a staining fluid (10 per cent, solution), 
is used for diagnostic purposes only, just as fluorescin. It 
stains ulcerated surfaces on the cornea red. 

Salt (chloride of sodium), in solution (a teaspoonful 
to the pint) , is used for cleansing the eye and for neutral- 
izing the excess of nitrate of silver when the latter is ap- 
plied in strong solution to the eyelids. 

Collodion (flexible) is used for dressing small wounds 
about the lids. At times it is painted on the lower lids to 
prevent inversion of them, when such inversion is due to 
spasmodic contraction, as sometimes happens after opera- 
tions on the eyeball, e.g., cataract extraction. 

Vaseline is obtained from petroleum by distillation. 
There are two preparations : the yellow and the white. If 
properly made there is little choice between them. Vaseline 
is used largely as a base for eye salves and as a dressing 
after operations on the lids ; also frequently to prevent the 
lids from sticking together. It may be obtained in tubes 
which is most convenient for use about the eye, and is also 
the best way of keeping vaseline sterile. 

Lanolin is obtained from the grease of wool, and is 
used extensively as a base for ointments. It is rather stiff 
when used alone and for that reason is often combined with 



90 



EYE NURSING. 



vaseline or rose water. It has one advantage over vaseline 
as a base — that is, it mixes with watery solutions. 

Glycerine, in solution (10 per cent.), is frequently 
used as a vehicle for various eye drops, especially where the 
drops are used in chronic inflammation of the lids, as in 
trachoma. 

Camphor water as a vehicle for drops is frequently 
used in the eyes. 

Boracic acid, sterilized, in saturated solution, and 
sterilized distilled water are commonly used as vehicles for 
eye drops. 

Bloodletting. 

Local bleeding is at times employed in deep-seated in- 
flammations of the eye, as in iritis and iridocyclitis. This 
may be accomplished by cupping the temple or back of the 
ear, or by applying leeches to the temple, or side of the nose, 
preferably on the temple. At times an artificial leech is 
used, which is nothing more or less than "cupping" with a 
special instrument devised by Heurteloup. The object of 
leeching is to draw away the blood from the inflamed tis- 
sues, thereby relieving pain and lessening the inflammatory 
process. The bloodletting may be repeated at two or three 
days' interval. To apply the natural leech, the nurse should 
first wash the spot to which the leeches are to be applied, 
then holding the larger, bulkier end of the leech in a towel 
apply the smaller end of the leech, which is the head or 
biting end, to the temple ; or the leech may be placed in a 
small glass tube and held to the temple. If the leech does 
not "stick," a drop of blood can be drawn with the prick 
of a lancet at the site desired, when, as a rule, it at once 
takes hold. Two to six leeches may be applied at one sit- 
ting. They should be allowed to remain on till they drop 



BLOODLETTING. 



91 



off and subsequent bleeding encouraged by the application 
of warm, sterile water. ' It is sometimes difficult to stop the 
flow of blood after leeching. A small pledget of cotton 
soaked with perchloride of iron applied to the seat of bite 
and gauze placed over this and a pressure bandage applied 
is effective in stopping the bleeding. Leeches should be 
used but once. A supply may be kept on hand indefinitely 
in black earth. 

The artificial leech or cup is applied by first rendering 
the site of application clean, then scarifying and placing the 
cup on and allowing it to draw. Subsequent bleeding may 
be encouraged by warm applications as after the natural 
leech. 

Not only is local bloodletting of value in relieving 
the congestion and allaying pain in iritis, but frequently is 
of great service as an adjuvant to mydriatics in dilating the 
pupil and breaking up synechiae between the iris and lens. 
The withdrawal of the blood by lessening the bulk of the 
iris allows the mydriatic to act more forcibly. 

Leeches should not be applied to the lids or the con- 
junctiva, as they cause local irritation at times, and the 
bleeding would be most difficult to stop, since there is no 
firm surface beneath to make pressure against, the only 
method of stopping the flow quickly and efficiently. 

Poultices are no longer used in ophthalmic practice 
except by ignorant and uninformed individuals. The laity 
are prone to use poultices, but fortunately are being edu- 
cated to dispense with these unhygienic and dangerous ap- 
plications. In hopeless cases, as in panophthalmitis, Avhere 
there is no chance of saving the sight, a poultice may be 
used to alleviate the pain. Under no other conditions 
should it be at 'all considered. 



CHAPTER VI. 



REMEDIES AND THEIR APPLICATION {Contwued). 

The Application of Drops — Lotions and Solutions — Solids — 
Powders — Ointments — Cold — Heat — Massage — 'Pressure — Hypoder- 
mic Injections of Strychnine — Mercury — Pilocarpine, etc. 

Drops. 

These are applied to the eyes and lids for varying pur- 
poses, e.g., to dilate the pupil and paralyze the ciliary mus- 
cle, as in iritis; to contract the pupil in glaucoma; for in- 
flammatory conditions of the cornea and conjunctiva; and 
to produce local anesthesia preparatory for operation. For 
convenience of use and in order to keep these drops sterile 
they are kept in bottles which are closed with pipettes or 
droppers ground at their upper extremities in the shape of 
a stopper, which fit air-tight into the neck of the bottle. 
The upper end of the dropper has a rubber nipple which 
serves to close the opening, and also, by exhausting the air 
from it and releasing the pressure, to draw a few of the 
drops from the bottle, which may be instilled one by one 
into the eye by gently squeezing it (see Fig. 3). Chalk's 
eye-drop bottle has a thin sheet of India rubber tied across 
the upper, cup-shaped end of the dropper, and the drops 
are drawn into it by first pressing the finger on the rubber, 
then relieving the pressure when the drops are drawn into 
the tube, when they may be dropped into the eye (see 
Fig. 4). Andrews's aseptic eye-drop bottle is shown in Fig. 
5, and Galezowski's in Fig. 6. Stroschein's aseptic bottle 
is shown in Fig. 7. It is made of thin glass, is flask-shaped, 
and the solutions can be sterilized in the bottle by boiling. 
(92) 



EYE DROPS. 



This makes it very convenient for operations and where 
fresh solutions cannot be had frequently. The pipette is 
made with a constriction in it just above the stopper part 
(C 1 ), and above the constriction tbere is another stopper- 
shaped bulb (C 2 ), and on the end of this second stopper is 
an olive-tipped bulb over which the rubber nipple fits. The 




Fig. 3. — Showing Method of Instilling Drops into the Eye. 

pipette is constructed in this manner so that the rubber 
nipple may be removed and the pipette reversed and in- 
serted into the bottle when the solution is to be sterilized. 
The flask is then held over a flame (gas jet or alcohol lamp) 
for three minutes, bringing ihe solution to a boil, thus 
sterilizing it. The steam escaping through the pipette and 
around the loose-fitting upper bulb of the pipette serves to 



94 



EYE NURSING. 



sterilize these. The flask may be held on wire gauze sup- 
ported by a tripod while over the flame, or with a clamp. 
The rubber nipple may be sterilized by boiling, or by dip- 
ping into strong bichloride of mercury solution and rinsing 
with sterile water. One minute after sterilization, the 
pipette can be reversed (with aseptic fingers, of course), the 




Fig. 4. — Chalk's Eye-drop Fig. 5. — Andrews's Aseptic 
Bottle. Eye-drop Bottle. 

nipple attached, and the drops are ready for use. In order 
that the solution may not be made stronger from evapora- 
tion through boiling a few drops of sterilized water may 
be added before boiling the drops. 

The usual method of instilling drops into the eye is to 
sit in front of the patient, the patient also being seated; 
pull the lower lid down with the index or middle finger; 
have the patient look up, and gently instill one or more 
drops on the inside or mucous surface of the lower lid near 



EYE DROPS. 



95 



the outer corner of the eye. The lid is then released, and by 
"blinking" the eyelids the patient distributes the fluid over 
the eye. If the patient is an adult and not nervous, the 
upper lid may be raised with the thumb or forefinger, the 
patient told to look down, and 1 or 2 drops of the solution 
dropped directly on to the cornea. Eefractory patients 
should be made to lie down, or the patient's head taken 
between the knees, the lids gently held apart with the 
thumb and forefinger, or both hands used, while a second 
attendant instills the drops. When drops are used for af- 
fections of the lids, these must first be everted (see page 




Tig. 6. — Galezowski's Eye-drop Bottle. 



96) and the drops applied freely, any excess being taken 
up with absorbent cotton. In the application of drops to 
the eye the dropper should not be allowed to touch the eye, 
neither should it be held too far from the eye, especially if 
the drops are to fall on the cornea, as they cause the patient 
to jump, and often shock a nervous patient. After apply- 
ing drops to the eye the nurse must never fail to place the 
finger over the tear-sac at the inner canthus, holding it 
there for two or three minutes and by pressure prevent the 
excess of fluid from running into the nose ; or the lids may 
be held from the eyes for a few moments, thus preventing 
drainage into the lacrymal ducts and into the nose. Par- 
ticular care should be exercised when strong solutions of 
atropine, scopolamine, cocaine, or any of the powerful alka- 
loids are employed. It must be remembered that it takes 



96 



EYE NURSING. 



but a very few drops of a 1 per cent, solution of atropine 
(the- ordinary strength used in the eye) to contain the 
maximum dose of that drug as administered internally. 
By allowing several drops of such a solution carelessly to 
drain into the nose of a child or weakly adult it is easily 
understood how poisonous symptoms could be brought 




Fig. 7. — Stroschein's Aseptic Drop Bottle and Stand. 



about. I presume it is almost unnecessary to say that the 
nurse should wash her hands after instilling such drugs, if 
she wishes to avoid applying some of the same to her own 
- eyes by rubbing them. 

Application of Lotions and Solutions. 

In order properly to apply lotions to the eye the lids 
must be everted. To evert the lower lid place the thumb or 
index finger on the lower lid just below the lashes and near 
the center and pull directly downward. To evert the upper 



APPLICATION OF LOTIONS AND SOLUTIONS. 97 

lid have the patient look down, catch the lashes between the 
thumb and index finger of one hand, and pull the lid gently 
forward from the eyeball, while sudden pressure downward 
is made at the upper edge of the cartilage with the index 
finger of the free hand. Unless there is marked swelling of 




Fig. 8. — Glass-Stoppered Aseptic Drop Bottle. 

the lids, or we have an unruly patient, the lid is easily 
everted by this simple manipulation. With children we 
may be compelled to place the child's head between the 
knees, before it can be accomplished successfully and with- 
out harm to the eye. 

Once the lids are everted, all cleansing lotions are 
easily applied by squeezing the solution out of a pledget of 

7 



9b 



EYE NURSING. 



cotton on to the lids; any remaining secretion not washed 
away in this manner must be wiped away from the lids with 
the moistened cotton, care being taken not to touch the 
cornea. Solutions not meant for cleansing, but as a local 
medication to the lids, are best applied with cotton wound 
smoothly on an applicator, saturated in the solutions, and 
rubbed on to the surface of the everted lids. The lower lid 
and cul-de-sac are easily treated in this manner. To reach 
the upper cul-de-sac with probe and cotton or solid stick of 
blue stone or alum is a more difficult matter, unless the fol- 
lowing maneuver is used, which renders it easy and safe : 
First release the lower lid ; after the application is made to 
that part, have the patient look down, evert the upper lid, 
and make pressure on the upper edge of the everted lid 
with the thumb ; then tell the patient to shut the eye (usu- 
ally unnecessary, especially with children who try to close 
the eyes). The pressure at the upper edge of the everted 
cartilage throws the everted upper lid outward over the 
lower lid, which latter is squeezed upward under the everted 
upper lid and at the same time protects the cornea from in- 
jury. The application is now carried far up into the upper 
cul-de-sac, where it should go, and without any danger 
whatever to the cornea, as the lower lid effectively protects 
that part of the eye. The applicator (or pencil if solids 
are being used) is held horizontally and the whole length 
of the cul-de-sac is touched at once. The tighter the lids 
are squeezed, the farther down is the cul-de-sac brought and 
the more easy and thorough the application (see Fig. 9). 
I have found the above method of technique so simple and 
so valuable, particularly so with children, that I have ven- 
tured to give it in detail. All the writers T have consulted 
say that no attempt, except by an expert, should be made 
to reach the upper cul-de-sac because of the danger of in- 



APPLICATION OF LOTIONS AND SOLUTIONS. 99 



jury to the cornea. By this method any competent nurse 
can do so with safety. I am firmly convinced that many 
cases of chronic inflammation of the lids are much pro- 
longed because of inefficient and insufficient application 
of the intended remedy to the upper cul-de-sac where it is 
most needed. 




Fig. 9. — Showing how to Make Application to the 
Upper Cul-de-sac. 

Eubber-tipped bulbs or rubber bulbs with rubber 
nipples, syringes, atomizers, etc., should never be used to 
apply lotions to the eye. They are inefficient, dirty, and 
dangerous, both to the patient's and the operator's eyes ; to 
the patient by injury to the eye, to the surgeon and nurse 
by squirting infectious material into their eyes. 



100 



EYE NURSING. 



Where the lids are very much swollen, as in gonorrheal 
ophthalmia, a retractor may be required to lift the lid from 
the eyeball (see Fig. 10), in order to properly cleanse the 
eye and make the necessary application. This is to be done 
carefully, the edge of the lid being lifted slightly from the 
globe by traction at the upper part of the lid with one hand 
and the edge of the retractor slipped beneath the lid and 
pulled upward and backward to expose the eyeball for 
cleansing and for the application of remedies. There has 




Fig. 10. — Showing Method of Placing Retractor 
Under the Upper Lid. 



been devised a hollow retractor with a rubber tube attached 
to the handlesi with perforations in the "curved" portion, 
so that a solution may be transmitted through it while in 
situ, thus cleansing the eye. Its use is not satisfactory, 
solutions squeezed from pledgets of cotton being more 
efficient and less dangerous to the eyes, both of the patient 
and of the operator. Camel-hair brushes should never be 
used to apply liquids to the eye, as they are difficult to keep 
clean and the danger of infection being transmitted by 
them is too great. Cotton wrapped on an applicator, dip- 
ped into the solution, is by far the best method of making 



APPLICATION OP SOLIDS. 



101 



such applications, for the cotton is used but once and 
immediately destroyed. 

Eye-cups are sometimes prescribed for patients with 
which to apply healing lotions to the eyes where the serv- 
ices of a nurse are not required, as in the milder inflamma- 
tion of the eyelids. They are also at times used as a means 
of applying hot or cold water to the eyes. They are used 
in the following manner : The cup is filled to within from 
an eighth to a quarter of an inch of the top with the solution 
to be applied, the head is bent forward, the cup applied 
firmly over the closed eye, then the head is raised and held 
slightly backward and the eye opened and closed several 
times. The head is leaned forward again and the cup re- 
moved. The second eye may be treated in a similar man- 
ner. Each patient should have his own eye-cup, otherwise 
infection might be transmitted. 

Application of Solids. 
Pencils of sulphate of copper (bluestone), alum, miti- 
gated silver stick (made by fusing 1 part of nitrate of silver 
and 2 parts of nitrate of potassium), lapis divinus (equal 
parts of bluestone, alum, and nitrate of potassium, with 2 
per cent, of camphor added), are the solid preparations 
commonly applied to the eyelids in the treatment of tra- 
choma and chronic affections of the conjunctiva. Pencils 
of these preparations are mounted in holders which have 
caps to cover them when not in use (see Fig. 11). When 
applied to the lids they should first be dipped into clean 
water, then the lower lid everted, and the pencil, held in the 
horizontal position, applied the full length of the lid and 
into the cul-de-sac. The lower lid is then released, the 
upper lid everted, and the patient told to close the eyes, 
when the upper lid, by slight pressure at the upper edge of 



102 



EYE NURSING. 



the everted lid, is slid down over the lower lid, which covers 
and protects the cornea. The pencil in the horizontal posi- 
tion is applied to exposed surface of the lid and then into 
the upper cul-de-sac. If there is any pus or muco-pus in the 
eyes, this should be washed away before the pencils are ap- 
plied. Any excess of the remedy, as coagulated material 
after application of the silver stick, may be wiped away 
with a pledget of cotton moistened in boracic acid or salt 
solution and squeezed as dry as possible. Where the bi- 
chloride of mercury solution (1 to 500) is applied with 
cotton and applicator, as it is in trachoma, or silver solution 
in acute ophthalmia (10 or 20 grains to 1 ounce) the excess 



Fig. 11. — Alum Pencil and Holder. 

may be washed away with sterile water, or salt solution 
(1 per cent.) in case of silver. 

The nurse should sit in front of the patient, or stand 
back of the patient (the patient sitting in each instance), 
when the solid applications to the lids are made. In case of 
children they may be held in the lap of a second nurse, and 
the head of the child between the knees, as shown in Fig. 1. 

Application of Powders. 

The various powders, such as calomel, iodoform, and 
boracic acid, are best applied to the lids or the eyes by 
means of a camel-hair brush. The patient's head should be 
held tilted backward, and the lids opened with the thumb 
and forefinger of one hand, while a little of the powder is 
flipped on to the corftea from the brush, being careful not 
to touch the cornea with the brush. Where the remedy is 



APPLICATION OF HEAT. 



103 



to be applied to the lids, they should be everted and the 
powder dusted on them. 

Application of Ointments and Salves. 

Ointments are best applied to the eyeball by means of 
a very narrow short spatula or by means of a small glass 
rod. The lower lid is drawn downward with the finger, and 
the spatula or rod, with a little of the ointment on it, is 
rubbed on to the everted lid. When it is allowed to go back 
into position and the eyeball massaged for a minute or two 
with the tip of the index finger over the closed lids to thor- 
oughly apply the ointment. The spatula, of course, is to 
be cleansed before using on a second patient. 

To apply ointment to the edges of the lids, as in ble- 
pharitis marginalis, the lids are first thoroughly cleansed 
of all scales and scabs with a warm solution of boracic acid 
or soda, then dried, and the ointment rubbed on the edges 
of the lids, which are closed, with the finger. In case of 
children it is best to place the child's head between the 
knees, both for cleansing the eyes and applying the oint- 
ment, powders, or other remedies. 

Where inunctions of mercury are given, the nurse 
should be careful to protect her hands with rubber gloves, 
so as not to medicate herself. Mercurial ointment may be 
rubbed into the temple or on any other portion of the body, 
preferably under the arms and inside the thigh, and is de- 
signed to remove constitutional disease which causes certain 
diseases of the eye, as iritis, scleritis, etc. 

Application of Heat. 
Heat is applied to the eyes for the purpose of relieving 
pain, preventing inflammation, the promotion of absorption 
of inflammatory products, and to hasten the formation of 



104 



EYE NURSING. 



pus in the later stages of inflammation. It may be applied 
in dry or moist form. The application of heat is especially 
indicated in inflammations of the cornea, of the iris, and 
deep-seated inflammations of the eyeball. 

Dry Heat. — 1. This may be applied to the eye by 
means of the electric heated pads, which can be attached to 
any incandescent lamp by a cord which is supplied with the 
pad. These pads can be had at most drug stores and elec^ 
trical supply houses. They are very convenient, light, and 
easily applied. Of course, electricity in the house or hos- 
pital is a necessary requisite to its use. 2. Pads of cotton 
wool or several layers of gauze heated in an oven and placed 
on the closed eye and covered with oiled silk and held on by 
a bandage is a convenient method of applying dry heat. 
3. A thin layer of rubber protective may be placed over the 
closed lids and hot wet compresses of absorbent cotton or 
wool may be applied over this. The rubber keeps the eye 
dry, and the effect of dry heat is thus obtained. 4. A very 
small hot-water bag may be used upon the eye, but this has 
the disadvantage of being heavy and causing pain by its 
weight. 

Moist Heat. — This is best applied by means of pledgets 
of absorbent cotton or wool. The lids of the eye are greased 
with vaseline that the skin may not be blistered. A basin 
of sterilized water (made so by boiling and allowing to cool, 
115° F.) is placed on a tripod or a couple of bricks, near 
the bed, and a spirit lamp or gas jet placed under it and so 
regulated as to keep the temperature at about 115° F. The 
pledgets of wool or cotton, which should be rather thick, are 
dipped into this, wrung out, and placed on the eye. They 
should be changed every two minutes and this should be 
kept up for fifteen minutes to half an hour, according to 
directions of the surgeon. If the pledgets become soiled 



APPLICATION OF COLD. 



105 



from secretions they should be destroyed and fresh ones 
used. 

Application of Cold. 

Cold is used on the eyes and its appendages to relieve 
pain and to prevent and relieve inflammatory symptoms. 
In inflammatory conditions of the lids and conjunctiva, as 
in purulent and gonorrheal conjunctivitis, it is indicated 
particularly in the early stages. In the later stages hot 
applications are indicated, especially if the cornea becomes 
involved. In injuries of the eye cold is also indicated. Cold 
may be applied in dry or moist form. 

Dry Cold. — 1. This may be applied by putting finely 
cracked ice in a small rubber bag and placing it on the eye. 
This method is objectionable because of the weight of the 
ice. 2. The Leiter coil, which consists of metal tubing of 
small caliber, coiled, as its name implies, so as to form a 
disc, is a convenient way of applying dry cold to the eye. 
One end of the tubing is connected by means of a rubber 
tube with a large basin of iced or cold water, and this is al- 
lowed to drain through the coil, which rests upon the closed 
eyelids. A thin layer of gauze may be placed over the lids 
that the coil may not come in direct contact with the lids. 
The water from the coil is caught in a second basin, and 
poured again into the first basin if the application is to be 
made for a long while. As a rule, twenty to thirty minutes 
at one sitting is quite long enough to apply cold. The 
objection to the Leiter coil is its weight, which is often un- 
comfortable to the eye. 

Moist Cold. — The best method of applying moist cold 
to the eyes is by means of pledgets of absorbent cotton 
moistened and placed on a large cake of ice, allowing them 
to get thoroughly cold, then applying them to the closed 



106 



EYE NURSING. 



eyelids. The cake of ice should be large enough to have 
room for four or six pads of cotton on it at once, so that 
some of the pads are cooling while those on the eye are in 
use. The pads should be changed on the eye about every 
minute, or two minutes at the furthest, and this should be 
kept up for from twenty minutes to one-half hour at a 
time. This may be repeated every two or three hoursi dur- 
ing the day. 

Subconjunctival Injections. 

In recent years subconjunctival injections of bichloride 
of mercury have been recommended in certain eye diseases, 
such as scleritis, episcleritis, irido-choroiditis, etc., with the 
claim that the remedy has a more direct and specific action 
than when given by other methods. The conjunctiva is first 
anesthetized by a few drops of a 4 per cent, solution of 
cocaine; then the ocular conjunctiva near the equator is 
picked up with a fine pair of forceps and 8 to 12 minims 
of a 1 to 1000 solution of bichloride of mercury and 4 to 
6 minims of a 1 per cent, solution of cocaine are injected 
with a hypodermic syringe under the conjunctiva. There 
is always reaction from this injection ; sometimes it is very 
marked, causing much pain. It should not be repeated 
until the reaction has subsided. This mode of treatment 
;has not met with much favor in this country. A less 
severe injection under the conjunctiva is a simple normal 
salt solution, which has been found to be equally efficacious 
as the bichloride solution, the inference being drawn that 
the benefit secured is from the stimulation of the lymph 
channels, thus increasing the elimination and hastening the 
cure. Other remedies may be given in this way, but only 
by the physician. 



MECHANICAL REMEDIES. 



107 



Mechanical Remedies. 

Mechanical remedies, such as pressure and massage, are 
frequently used in diseases of the eye. The pressure band- 
age is used in ulceration of the cornea as a means of pro- 
tection and to keep the eye and the lids quiet ; also to pre- 
vent a perforation of the cornea in deep ulcers of that mem- 
brane; to prevent staphyloma (bulging forward) of the 
cornea; to promote the absorption of extravasations of 
blood in the lids; also fluid effusions inside the eye, as in 
detachment of the retina; to prevent excessive swelling of 
the lids after the operation of "expression" or "grattage" 
for trachoma ; and to prevent hemorrhage. For the method 
of applying a pressure bandage, see Chapter X. Where 
there is marked secretion from the conjunctiva bandaging 
is contra-indicated, unless the bandages are removed fre- 
quently to allow the eye to be cleansed. 

Massage of the eyeball and the eyelids is sometimes 
practised with benefit. That which the nurse will be called 
upon to give will be massage of the eyelids, and occasionally 
massage of the eyeball indirectly through the lids. The lid 
affections calling for massage are : ( 1 ) blepharitis, in 
which the yellow oxide of mercury ointment is rubbed into 
the edges of the lids by a horizontal motion of the finger- 
tip over the lids; (2) in chronic conjunctivitis, simple mas- 
sage of the lids by horizontal or rotary strokes improves the 
condition by stimulating the blood and lymph flow and 
getting rid of inflammatory products; (3) in deposits of 
blood under the skin of the lids, after blows, etc., massage 
is of service in hastening absorption; (4) spasm and 
twitching of the orbicular muscle are often relieved by 
massage over the lids and the brow. 

The diseases of the eyeball which have been benefited 



108 



EYE NU USING. 



by massage are: (1) phlyctenular keratitis, in which a 
small portion of yellow oxide of mercury ointment is placed 
between the lids and then massage of the eyeball is made 
by rubbing the lids over the globe for a few moments ; ( 2 ) 
in noninflammatory glaucoma, where treatment by medi- 
cines or operation is of little avail, massage of the globe 
through the lids is of benefit in reducing the tension. 
Rapid rotary movements with the finger-tip are first made 
over the upper lid, the lower lid being pushed firmly against 
the eyeball below to steady it; then like movements are 
made over the lower lid, the upper one being held firmly 
against the eyeball above. Instead of rotary movements, 
backward strokes from the center of the lids may be made. 
Unfortunately the reduction of tension in the eye by this 
method of treatment remains but a short time. 

Massage of the globe by means of a stream of hot water, 
115° to 120° F., to remove corneal opacities of a superficial 
nature, has been recommended, but in my experience, after 
trying it faithfully, the method proved of but little value. 

Hypodermic Injections. 

In deep-seated affections of the eye, as in the choroid, 
retina, and optic nerve, hypodermic injections of strychnine 
are frequently required. The nitrate of strychnine is pre- 
ferred to the sulphate for injecting under the skin, as it is 
less irritating. In optic atrophy due to the use of alcohol 
and tobacco the nitrate of strychnine in increasing doses, 
beginning with 1 minim of a solution of 1 grain to the 
drachm, and increasing the dose 1 minim a day until phys- 
iological elfect is reached, is of marked benefit. The use of 
tobacco and alcohol is to be stopped as part of treatment. 



HYDROTHERAPY. 



109 



Diaphoresis. 

Hypodermic injections of muriate of pilocarpine, in 
dose of y 10 to y 5 grain, are often employed hypodermically 
where there is serous exudates in the eye, as in detachment 
of the retina, to produce excessive sweating. It is also em- 
ployed in some forms of optic atrophy. The nurse cannot 
be too particular in preparing the site for the injection, also 
in the care of the syringe, needle, and solution in giving 
these injections, as abscesses are liable to follow the injec- 
tion. The injection should be given deep in the muscle of 
the arm or leg, and a little gentle massage made for some 
moments over the spot to promote the absorption of the 
drug. When profuse sweating has been caused, the night- 
clothes should be changed for dry ones. 

In some syphilitic and rheumatic affections of the 
deeper tunics of the eye, sweating is of pronounced benefit, 
and this may be accomplished without the use of drugs, as 
by the dry pack. Here the nurse wraps the patient in a 
blanket and covers him warmly in bed, at the same time giv- 
ing the patient free draughts of hot water. If the sweating 
is not free enough the patient may first be given a hot bath, 
then wrapped in blankets, and jaborandi added to the hot 
water which the patient drinks. Hot-air baths may be used 
for causing profuse sweating. 

Hydrotherapy. 

In addition to local hydrotherapy general hydrotherapy 
is employed in many affections of the eyes, as in ulcerations 
of the cornea, phlyctenular conjunctivitis, episcleritis, and 
in the various rheumatic and syphilitic diseases of the eye. 
The beneficial effects are produced, no doubt, by improve- 
ment in the general condition, increased elimination, and 



110 



EYE NURSING. 



the tonic and sedative effect brought about by the bathing. 
I have seen, in more than one instance, the steady advance 
of a destructive ulceration of the cornea checked by Turkish 
baths, and this after all other means of relief had failed. 
For the various methods of giving hot baths, cold baths, foot 
baths, etc., the nurse must be referred to books on general 
nursing and hydrotherapy, as the space in this small volume 
is too limited to delve into those subjects. 

Diet. 

In many diseases of the eye the proper regulation of 
the diet of the patient as to the kind and the amount of food 
to be given is of great importance. The nurse will be called 
upon to look after the diet in operative eases especially. 
Where the disease of the eye is dependent upon some con- 
stitutional trouble, as it is in albuminuric retinitis, diabetic 
retinitis; and in iritis, episcleritis, etc., of gouty origin; 
the diet of the patient must be suitable to combat the gen- 
eral disorder. In certain diseases of the eyelids, as blepha- 
ritis marginalis, and in some affections of the eyeball, 
phlyctenular keratitis and conjunctivitis, diseases most 
often seen in children of a scrofulous diathesis, diet is of 
the utmost importance in effecting a cure. Without excep- 
tion, in these latter cases, sweets and pastries of all kinds 
should be withheld, while a simple plain diet should be in- 
sisted upon, such as milk, bread and butter, oatmeal, 
hominy, rice, eggs, fresh meat once a day, as lamb chops, 
turkey, chicken, etc. ; vegetables, potatoes, string beans, 
peas, tomatoes, lettuce, chicory, and ripe fruit in limited 
quantity. Tea and coffee, as a rule, are not good for such 
patients. In ulceration of the cornea and other affections 
due to malnutrition, especially in old and in feeble patients, 
a mild stimulant, as a weak milk punch, may be added to 



QUIET, REST, AND SLEEP. 



Ill 



the diet. In fever patients a fluid diet is to be given, such as 
milk, soups, etc., or a semifluid diet, as oatmeal, mush, or 
soft-boiled eggs. After operations on the eyeball where the 
anterior chamber has been opened, as after cataract extrac- 
tion, not only is a special diet demanded for a few days, but 
the nurse is required to feed the patient, since the eyes are 
bandaged. In such cases, in order to prevent chewing and 
thereby disturbance of the wound, the patient is fed milk, 
broths, soups, etc., in the recumbent or semi-recumbent 
position and through a tube or from a spoon or a special 
cup, fluids constituting the main source of diet for a day or 
two, after which soft-boiled eggs, milk toast, shredded lean 
meat, oatmeal, etc., may be added to the diet. Great care 
must be exercised by the nurse, when feeding a patient in 
the recumbent position, not to feed him too fast or to give 
too large a morsel of soft food at once, because, if the pa- 
tient is choked and thrown into a fit of coughing, great 
harm may be done the eye, especially after cataract extrac- 
tion. As a rule, no fruits or food of a laxative nature 
should be given to cataract patients until two or three days 
after the operation, as it is desirable to keep the bowels 
from moving and the patient from straining at stool for at 
least that length of time after the operation. 

Quiet, Rest, and Sleep. 
In the serious inflammatory diseases of the eye, espe- 
cially those attended with much pain, and after operations, 
it is essential that the patient be in a quiet place that he 
or she may secure the proper amount of rest and sleep to 
sustain vitality, and thus hasten the cure. The nurse should 
talk to the patient only as in the course of her duty de- 
mands, and should allow the patient to talk but very little. 
On no account should friends be allowed to sit and talk 



112 



EYE NURSING. 



for a long time to a patient who is very ill or shortly after 
an operation on the eyes. Only recently a lady under my 
care with chronic inflammatory glaucoma was thrown into 
an acute attack lasting for a period of twenty-four hours be- 
cause the nurse allowed a friend of the patient to sit and 
talk to her for two hours. The patient told me that she was 
so utterly exhausted and so much irritated by the long visit 
that she could hardly retain her self-control and that her 
eye began to pain shortly afterward, though she had had 
no pain in it for a number of days previously. 

Sleep is essential to the healing process. If there is 
much pain an opiate must be given: morphine, % to % 
grain. If there is no pain, trional, in 15-grain doses, is a 
reliable hypnotic. Where the eye has to be looked after and 
cleansed every half-hour, as in gonorrheal ophthalmia and 
purulent ophthalmia, it is essential to increase the intervals 
between times for cleansing during the night, say, from 
one to two hours ; because, if the patient is kept awake con- 
tinuously for two or three days, the general strength is re- 
duced and the vitality so lowered that evil consequences 
result from lack of general nutrition and rest as well as 
from the local disease. 



CHAPTER VII. 



SEROIS AND VAGCENES, 

Diseases of the Lids — Conjunctivitis — Keratitis — Diagnostic 
Reactions: Subcutaneous Test — Von Pirquet"s Test — Moro's Test — 
Intracutaneous Tuberculin Test — Therapeutic Reactions — Other 
Vaccines and Seriuns — Preparing the Patient — Syringes — Site of 
Inoculation — Reactions. 

Since the administration of serums and vaccines are 
coming more and more into use in the treatment of certain 
diseases of the eye. the nurse should be trained not only in 
preparing the patient for their administration but should 
be familiar with the different methods of giving them and 
the symptomatic reactions following them. In fact the 
eyes furnish a most favorable field for the serum and vac- 
cine treatment, as the symptoms especially of a focal nature 
are so easily observed. E. W. Allen 1 , of London, in a quite 
recent monograph, speaks as follows: "I venture to say 
that no part of the body gives such striking result? in the 
vaccine treatment of diseases peculiar to it as the various 
parts of the eyeball/' 

Some of the diseases of the eye that particularly lend 
themselves to the vaccine treatment are : 

Conjunctivitis in the intensely acute forms or in the 
very chronic types : the infecting organism being the gono- 
coccus, pneumococcus. streptococcus, bacilli tuberculosis, 
Morax-Axenfeld, Koch- Weeks. Friedlander, coli. etc. 

Recurrent styes, due to streptococcus, staphylococcus. 



i Allen. R. W. : Practical Vaccine Treatment. London, 1919, 
H. K. Lewis. 

8 (113) 



114 



EYE CURSING. 



Lacrimal sac inflammations, due to streptococcus, 
staphylococcus, pneumococcus or colon bacillus. 

Keratitis, especially the infectious ulcers of the cor- 
nea due to the gonococcus, pneumococcus, and streptococ- 
cus; also in the recurrent phlyctenular forms of keratitis. 

ScLERiTis, due to bacillus tuberculosis, bacillus coli, 
pneumococcus, streptococcus, etc. 

Also in the deeper infections of the eyes as in the iris, 
ciliary body, choroid, retina, etc., often due to the strepto- 
coccus, pneumococcus, gonococcus, staphylococcus, and the 
tubercle bacillus, etc. 

Although I have had but little experience in vaccine 
treatment in general bodily diseases, except as affecting the 
eyes, I can fully confirm Allen's claims as to the efficiency 
of the vaccine treatment in the diseases of the eyes. In 
many infective diseases of the eye vaccine treatment is im- 
perative, if we would save the sight of the eye, the eye itself, 
and at times the life of the patient. 

Well do I remember one patient who had injured the 
upper eyelid, a druggist had closed the wound with ad- 
hesive plaster; twenty-four hours later, an abscess formed 
in the eyelid ; yet another 48 hours and the whole side of the 
face was swollen and the lymphatics of the neck enlarged, 
and high temperature followed. Prompt evacuation of 
the pus was made and a large dose of stock polyvalent vac- 
cine was given at once. An autogenous vaccine was made 
from the pus (streptococci and pneumococci being the in- 
fecting organisms) and a large dose (200,000,000) of this 
was given 48 hours after the stock vaccine. This was re- 
peated in 48 hours, and although part of the skin and 
muscular tissue of the upper lid sloughed away the eye was 
preserved with little deformity of the lid and with good 
vision. In my opinion the life of the patient was saved by 



CONJUNCTIVITIS. 



115 



this prompt action as the infection was acute and virulent. 
Of course this is an exceptional case, but it illustrates the 
value of vaccine treatment if used early and energetically. 

Another reason for the early use of the vaccine treat- 
ment in the acutely infective diseases of the eye is that such 
infections usually develop very rapidly and do much damage 
to the eye in a short time. Hence the great necessity for 
early and active treatment. Especially is this so in cases of 
gonococcic and pnenmococcic ulcers with hypopyon. In the 
subacute and more chronic infections of the eye as in some 
of the cases of chronic conjunctivitis, recurrent styes, kera- 
titis, scleritis, etc., the vaccines often yield brilliant results 
when all other remedies have failed. The nurse, therefore, 
who is engaged in special nursing should familiarize herself 
with the administration of the vaccines and the reactions 
following the injections of the vaccines so as to report to the 
surgeon in charge and properly chart the symptoms. 

Diseases of the Lids. 

Eecurrent styes and chronic blepharitis marginalis 
which have resisted other treatment, often yield to vaccine 
treatment. Staphylococci, occasionally streptococci, and 
infrequently acne bacilli enter into the etiology. An initial 
dose of 250 million staphylococci, 50 million streptococci 
and 5 million acne bacilli, followed by larger doses 
(double) at weekly intervals often effect a cure (Allen). 
However, it must be stated that the vaccines sometimes fail 
in these cases, at least such has been my experience. 

Conjunctivitis. 

In the chronic and more stubborn types due to the 
Koch-Weeks bacillus and the Morax-Axenfeld bacillus or at 
times the staphylococcus and the bacillus of Friedlander, 



116 



EYE NURSING. 



the vaccine treatment often proves of the greatest benefit 
in effecting a cure and this after the cases have been of 
very long duration. The initial dose in these cases should 
be from 100 to 250 million in adults and one-half to one- 
third this amount in the cases of children, increasing to 
double this amount or more in subsequent doses, the inter- 
val of doses is about five to seven days depending on the 
reaction produced by the injection. It is in the acute forms 
of hypopyon conjunctivitis that the vaccine treatment brings 
the most gratifying results with the saving of sight and the 
eyeball itself. In such cases Allen thinks that "vaccine 
treatment should be little short of compulsory." In these 
acute cases of gonococcal and pneumococcal conjunctivitis, 
especially when complicated with hypopyon, not only should 
the local treatment be given (which see under respective 
headings in preceding chapters) but active vaccine treat- 
ment should be instituted. The initial dose in such cases 
should be 250 million and subsequent dose up to 500 mil- 
lion or more at three- to five- day intervals. Children 
should have about one-half the dose of adults. 

Keratitis. 

In serpiginous ulcer of the cornea which is due to 
pneumococcal infection, Allen claims that vaccine treatment 
is especially efficacious, succeeding even in those cases where 
the serums have failed. It should be borne in mind how- 
ever, both by the surgeon and the nurse, that caretul and 
well directed local treatment in such cases is most essen- 
tial in addition to the vaccine treatment and should not be 
relaxed for an instant. Atropine, argyrol (50 per cent, 
solution), hot fomentations, and the actual cautery at 
times, all have their place in the treatment and should 
never be lost sight of. 



DIAGNOSTIC REACTIONS. 



117 



In the deeper infections of the eye, as in iritis, uveitis, 
the cure may be effected in some of the chronic cases only 
by vaccine treatment. Diseased teeth or tonsils may be the 
cause and the streptococcus viridans in such cases has often 
been found to be the inciting organism. Besides removal 
of the tonsils and removal or treatment of diseased teeth, 
often the vaccine treatment must be employed before a cure 
is effected. Unhappily, at times every treatment proves 
futile to avert the progress of the disease. 

In recent years it has been found that many affections 
of the eye, which may be situated in any part of the organ — 
the conjunctiva, cornea, sclera, iris, choroid, retina — may be 
due to the tubercle bacillus, or its toxins. In such cases the 
vaccine treatment is of the utmost importance. In addi- 
tion local and general treatment should be given ; atropine, 
hot fomentations, shaded glasses should be used, general 
tonics, and all hygienic surroundings should be attended 
to. So important are the reaction symptoms (diagnostic 
and therapeutic) following the tuberculin tests and treat- 
ment that I venture to give" a brief description of same here. 

Diagnostic Reactions. 
As is well known, the diagnostic value of tuberculin 
depends on the reaction it produces when brought in con- 
tact with the living organism, either by dropping it on 
mucous surfaces, rubbing it on the skin, by vaccination into 
the skin, or injecting it into the skin or under the skin. 
Of the nature of this action, or rather reaction to tuber- 
culin, some words of explanation are here necessary, though 
space does not permit a full description of same. 

Three factors are comprised in the tuberculin reaction : 
1. General or constitutional reaction, which consists 
in a rise of temperature, a feeling of malaise, accompanied 



118 



EYE NURSING. 



at times with vomiting, headache and eruptions on the body, 
the temperature changes being the most important symp- 
tom of the general reaction. 

2. A local reaction, resulting in a nodule or infiltration 
at the site of the vaccination or injection, which may be 
slight or extensive and may cause enlargement of the neigh- 
boring glands. 

3. A focal reaction, which consists of lighting up anew 
or increasing the inflammatory process at the site of the 
lesion. 

Of these three factors in the tuberculin reaction, in 
ophthalmic cases, the focal reaction is the most reliable 
as an indication that tuberculosis is the cause of the eye 
trouble, though the primary focus of infection may not 
necessarily be in the eye itself. 

The local reaction at the site of injection or vaccina- 
tion comes next in importance, while the general or con- 
stitutional reaction, of which temperature is the chief indi- 
cation, is the least important from a diagnostic point. The 
alteration of the temperature, a rise or a fall, is, however, 
the most important guide that we possess in administering 
the therapeutic injections of tuberculin ; but of this I shall 
speak later. 

For diagnostic purposes the old tuberculin of Koch 
is employed in several different ways, almost to the exclu- 
sion of all other tuberculins. The one exception to this 
is the washed precipitate of old tuberculin used by Cal- 
mette and others in the conjunctival tests. But even here 
many observers prefer the dilutions (1 per cent., as a rule), 
of Koch's old tuberculin to the precipitated solutions (0.5 
to 2 per cent.) used by Calmette and his followers. As the 
Koch solution is weaker, it is safer and not so apt to cause 
excessive reactions as the stronger precipitated solutions. 



DIAG NOSTIC REACT I ( L\ s. 



119 



The Subcutaneous Test. — All told, this is the best 
and most reliable of the tuberculin tests. Before it is given, 
however, the patient's temperature should be taken four 
times a day for two days previous to the test. If there is 
found any considerable temperature elevation it is best not 
to give the test until this has abated. 

The indications of a positive reaction are : 

1. Constitutional Symptoms : The chief of these is a 
rise in temperature which may be, and often is, accompanied 
by a feeling of depression and malaise, chilly sensations, 
headache, aching pains in the back and, at times, nausea 
and vomiting, and eruptions on the body. 

2. Local Symptoms : Redness and swelling at the site 
of the injection appear, sometimes accompanied by swell- 
ing of the near-by lymph-nodes. 

3. Focal Symptoms: In case of ocular tuberculosis, 
there is increased irritation and exudation at site of dis- 
ease ; pain, and flashes of light if the retina is involved. 

As to the constitutional symptoms, it is desirable not 
to have intense reactions but only a very slight rise of 
temperature, and neither should there be produced but 
the slightest focal reaction in the eye, especially if acutely 
inflamed already, because great and permanent damage 
may be done if the lesion is in the retina or choroid, by 
the excessive inflammation produced. 

The initial diagnostic dose of Koch's old tuberculin 
for injecting under the skin should not be greater than 
0.5 mg. If a reaction takes place it will occur usually in 
from six to ten hours and reach its height in from twenty- 
four to forty-eight hours. If the first injection is not posi- 
tive, after forty- eight hours, a second injection of 2 mg. 
may be given, and if this does not react in forty-eight hours, 
then a third injection of 5 mg. or 10 mg. may be given. If 



120 



EYE NURSING. 



no reaction follows, this is strong evidence that the ocular 
lesion is not of tuberculous origin. If a positive reaction 
takes place, especially if a focal reaction occurs in the eve, 
it is strong evidence that the ocular disease is due to a 
tuberculous lesion, the primary tuberculous lesion not 
necessarily being in the eye, as a tuberculous lesion in some 
distal portion of the body, as is well known, may cause ocu- 
lar disease. 

Von Pirquet's Test. — This test consists in vaccinating 
the patient with old undiluted tuberculin. The arm is usu-' 
ally the place selected. After cleansing with alcohol a 
small scarification is made, just sufficient to have a little 
oozing, but no bleeding. Then the tuberculin is rubbed 
into this spot and allowed to dry. A second scarification 
about one inch distant from this is made, simply as a con- 
trol. The arm is protected with a light piece of sterile 
gauze held on by strips of adhesive plaster. At the end of 
from twenty-four to forty-eight hours, the reaction, if posi- 
tive, is usually at its height. Three degrees of reaction are 
noted : (1) mild, where the skin at the site of the vaccina- 
tion is reddened and slightly infiltrated for a distance of 5 
or 6 mm. around the vaccination; (2) moderate, more red- 
ness and wider infiltration and slight elevation of skin, 
perhaps double that of the mild; (3) intense, where the 
redness and infiltration extends an inch from the vaccina- 
tion, accompanied at times with vesicles and occasionally 
with enlargement of the neighboring lymph-nodes. In two 
instances I have had, in addition, a constitutional reaction 
with rise of temperature, malaise, etc., and also a focal reac- 
tion in the eye. In one of these patients a Pirquet test had 
been made twelve days previously with a 25 per cent, solu- 
tion of old tuberculin, with a negative result. I may say 
that the subcutaneous diagnostic test confirmed the diag- 



DIAGNOSTIC REACTIONS 



J21 



nosis in these two cases and that therapeutic injections 
cured the patients of their ocular lesion, one a keratitis, the 
other a chorioiditis. 

A positive Pirquet test in young children is of value as 
indicating the presence of a tuberculous lesion somewhere in 
the body ; in older children it is of doubtful value, and in 
adults it cannot be depended on. When the Pirquet test is 
negative, however, especially when repeated a second time, 
it is practically certain that there is no tuberculous infection 
anywhere in the body. 

Moro's Test. — This is somewhat similar to Pirquet's 
test — in fact is a modification of it. A 60 per cent, oint- 
ment of old tuberculin (the base being lanolin) is used to 
make the test. A piece the size of a pea is thoroughly 
rubbed into the skin covering a space of from one to two 
inches in diameter. If positive, in from twenty-four to 
forty-eight hours, small papules appear at the site of appli- 
cation of the ointment, more or less numerous according to 
intensity of reaction. The test is. variable and not very- 
reliable. 

The Intracutaneous Tuberculin Test. — Here the tuber- 
culin is injected into the layers of the skin (infiltration) ; 
this is a very delicate test as to tuberculous infection, as is 
also the subcutaneous local or depot test. But both of these 
tests are positive so often, especially in adult life, that they 
are not of value for diagnostic purposes. 

My own method of procedure in a suspected case of 
ocular tuberculosis is to first make the Pirquet test with 
the undiluted old tuberculin of Koch. If the test proves 
negative it practically excludes tuberculosis as a cause. If 
still in doubt, however, the test is repeated in three or four 
days' time. If again negative, tuberculosis is excluded as 
a cause of the ocular trouble. If the Pirquet test is posi- 



122 EYE NURSING. 

tive, unless in a very young child, the test is supplemented 
by the subcutaneous test, 0.5 nig. of old tuberculin, being 
given. If this is negative, a second injection of 2 mg. is 
given ; if this is negative still, a third injection of 5 mg. is 
given. This proving negative, tuberculosis may be excluded 
as a cause. 

When the subcutaneous test proves positive, especially 
if a focal reaction takes place, we may decide definitely that 
the ocular trouble is of tuberculous origin, and proceed with 
therapeutic injections. 

Therapeutic Reactions. 

As to the methods of administration of tuberculin in 
the treatment of ocular diseases, I may say there are two 
schools of therapists. The first consists of those who wish 
to avoid reactions., especially of a focal nature, and, fol- 
lowing Wright's lead, they give extremely small doses of 
tuberculin, for example, T. 11. or B. E., the initial dose be- 
ing "^OjOoo to %o?ooo m S-> increasing the size of the dose 
very slowly, while the interval between doses is wide, from 
ten to twelve days, and the treatment is prolonged over a 
long period of time. The second school, consisting of those 
who wish to produce mild reactions, following the von Hip- 
pel method, begin with larger doses of T. R. or B. E., the 
initial dose being % 00 to /4ooo m S-> which is increased in 
size rather rapidly, y 500 to % 0 oo m g- eacn dose and the 
doses are given at intervals of from two to five days or, in 
some cases seven to ten days, until as much as 1 or 2 mg. 
may be given at a single dose, care being taken, however 
not to cause too great a reaction ; for example, not to raise 
the temperature more than 0.5 to 1° F. above normal, or to 
cause more than the mildest focal reaction in the eye, be- 



OTHER VACCINES AND SERUMS. 



123 



cause a severe reaction in the eye may cause a lasting injury 
to the vision. 

When the dose has been increased to the point of pro- 
ducing reaction, it should be held at this till the reactions 
cease, then gradually increased again, with slightly longer 
intervals between doses, till slight reactions are again pro- 
duced, then repeat the procedure as before. This method is 
followed until the reactions cease or the patient is cured. 
The temperature is the most important guide we have in 
regulating the course of the treatment; this, together 
with the general condition of the patient, whether he is 
made to feel stronger and more cheerful, or is depressed 
(put in the '"'negative phase," so to speak), and a close 
observation as to any focal reaction, gives us all the evi- 
dence we need by which to proceed. 

Other Vaccines and Serums. 
The serums most commonly used in the diseases of the 
eye are: (1) The well known antitoxin (diphtheritic) 
which is used to neutralize the toxin or poison secreted by 
the diphtheritic bacillus, and (2) antibacterial serums such 
as are used to destroy the pneumococcal and streptococcal 
bacilli themselves. The remedies may be given intramus- 
cularly or intravenously, but the more common way is to 
give them subcutaneously. While it is a very common pro- 
cedure to give the antitoxin (antidiphtheritic) in cases of 
laryngeal and nasal diphtheria, it is rare to administer it 
for ocular diphtheria, because the infection in the eye usu- 
ally is secondary to the throat infection. However, subse- 
quent injections are often necessary and the nurse should be 
familiar with the method of giving same. As the method 
of preparing the patient and the precautions as regards her- 
self and the public in such cases have been gone into very 



124 



EYE NURSING. 



thoroughly by Dr. Douglass in the section on diseases of 
the throat, the reader is referred to that section, Chap- 
ter VI. 

Preparing the Patient. 

The temperature, pulse, blood-pressure and the gen- 
eral condition of the patient should be ascertained before 
any vaccine or serum treatment is undertaken. The run 
of the temperature morning, noon, and night should be had 
"for two or three days in cases where diagnostic doses of 
tuberculin are to be given (which see above). 

Syringes. 

The best syringe for giving the injections is that of 
Luer, which is all glass and graduated both in minims and 
cubic centimeters, and vary in capacity from 1 to 10 c.c. 
Not only are they well made but the needles are sharp and 
extra needles may be had in separate boxes. Before giving 
the injection the needle and syringe should be boiled in 
absolute alcohol and after injection the needle should be 
again disinfected and dried, and the piston left out of the 
syringe — the needle of course having a wire inserted to 
keep the opening free. 

The Site of the Inoculation. 

This is of some importance ; first, the injection should 
be in a place where the circulation is active ; second, in case 
of a female the arm should be avoided, so in case a scar 
should result that it would not show. In the male, usually 
the upper arm, abdomen, or the buttocks is selected for the 
injection ; in the female, the site of the injection is between 
the scapulae, the abdomen, or the leg. In very stout subjects 
the buttocks and the abdomen should be avoided when deep 



REACTIONS. 



125 



injections are given, as the thick layer of fat in such pa- 
tients prevents the rapid absorption of the remedy and may 
even endanger the life of the patient. Allen cites a case 
w here a mixture of adrenalin and pituitary extract was in- 
jected into the buttocks. "Three inches of fat lay over the 
muscles ; the highly vaso-constrictor fluid failed to absorb, 
autoinfection by the bacillus coli ensued, and the patient 
died of septicemia." 

Having selected the site of the injection the part should 
be painted with a three and a half (3%) per cent, solution 
of iodine; or the parts may be cleansed with green soap 
and water and followed with a %ooo solution of bichloride 
of mercur}', or 95 per cent, alcohol. 

Some of the complications following these injections 
may be : ( 1 ) piercing a small vein resulting in a marked 
discoloration, or, at times a hematoma; (2) piercing a 
nerve sheath, when the pain may be severe if the injection 
is given in the nerve sheath; (3) abscess formation may 
follow if the injection is not given under strictly antiseptic 
precautions. According to Allen, abscess formation may 
follow in some cases even where all antiseptic precautions 
have been taken, e.g., where large doses in small bulk are 
injected and the absorption is slow. 

Reactions. 

The reactions following the diagnostic and therapeutic 
injections of the tuberculin vaccines have already been 
given in detail (which see above). The reactions following 
the subcutaneous injections of the other vaccines commonly 
in use, as streptococci, pneumococci, staphylococci, etc., 
briefly stated may be summarized as follows : (A) Local. — • 
Redness, swelling, tenderness, and pain may come on after 
six to twelve hours and usually pass away in from one to 



126 



EYE N I USING. 



three days. Occasionally, however, the local reaction may 
be very severe, that is marked edema, redness and pain with 
enlargement of the neighboring lymphatic glands may re- 
sult. In fact the pain may be so great as to call for an 
opiate and the application of very hot or very cold com- 
presses. (B) Focal. — Focal symptoms may appear in 
twenty-four to forty-eight hours or even for three or four 
tenderness, redness, pain, photophobia, lacrymation, etc. 
(C) General. — General symptoms may appear as early as 
six hours, usually after ten to twelve, but may be deferred 
twenty-four to forty-eight hours or even for three or four 
days, manifested usually by a slight rise of temperature, 
increased pulse rate, chilliness, rigors, and, at times, by 
vomiting and great depression. The temperature at times 
may go very high, or again the temperature may drop one 
to three degrees below normal — the so-called negative phase 
of the reaction, accompanied by weakness and great de- 
pression. 

Headaches are not uncommon, and skin eruptions of 
varying intensity, from simple erythema to urticaria and 
marked and extensive eruptions all over the body may re- 
sult. These eruptions and other unpleasant symptoms 
clear up after a few days as a rule. 

In administering all these vaccines it must be kept in 
mind both by the doctor and the nurse that powerful toxins 
are being used and that great harm and even fatal results 
may follow if the greatest care is not observed in giving 
them. The surgeon of course decides on the size and the 
interval of the dosage, but he must be guided in a great 
measure by the faithfulness with which the symptoms of 
the reactions are recorded by the nurse, and it is the nurse's 
duty not only to record temperature and respiratory changes 
but to make careful note of the general condition, appear- 



REACTIONS. 



127 



ance, and feeling of the patient following these injections, 
since they have a most important bearing on the handling 
of the case. For instance, change in the temperature or 
pulse rate may be accompanied by great depression, the pa- 
tients not infrequently stating that they feel "shot to 
pieces/' following the injection. On the other hand the 
temperature and pulse change may be decided and yet no 
depression or ill effect follow. It behooves the nurse, there- 
fore, in such cases to be especially alert and to note well all 
the symptoms in these cases where such powerful and toxic 
remedies are being given. 



CHAPTER VIII. 



OPERATIONS ON THE EYE. 

Asepsis and Antisepsis — Preparations of the Operating Room 
— Operating Table — Sterilization of Instruments, Ligatures, and 
Dressings — Preparation of the Patient — Anesthesia, General and 
Local — The Different Operations. 

Asepsis and antisepsis as practised in general surgery 
are to be followed in the same manner, with some modifica- 
tions, in ophthalmic surgery. In preparing the patient, op- 
erating room, instruments, dressings, solutions, etc., the 
same rigid antiseptic methods as in general surgery are fol- 
lowed, as is also by the surgeon, assistants, and nurses in 
disinfecting and making their own hands clean. In pre- 
paring the field of operation, especially when the eyeball is 
to be operated upon, the strong antiseptic solutions should 
not be used, as the eye, being such a delicate organ, is much 
irritated by their use and the success of the operation often 
imperiled. If used at all, it should be the day previous to 
the operation and the eye bandaged, and a mild, aseptic 
solution or sterile water used to bathe the eye just before the 
operation. 

Antisepsis and Asepsis. 

Antisepsis, in the broadest sense, as it pertains to sur- 
gery and surgical dressings, may be defined as the means 
and methods employed to destroy disease and pus-producing 
germs, while asepsis is the art and science of keeping free 
from such germs. 
(128) 



ANTISEPSIS AND ASEPSIS. 



129 



Antisepsis may be accomplished in various ways: by 
means of: (1) soap, water, and scrubbing; (2) the use of 
the chemical antiseptics, as solutions of bichloride of mer- 
cury, carbolic acid, cyanide of mercury, formalin, alcohol, 
ether, iodine, etc., or by heat, dry or moist. Dry heat and 
steam are employed largely for sterilizing dressings, band- 
ages, towels, aprons, and gowns, while instruments and 
solutions: are quickly and efficiently sterilized by boiling. 

Tincture of iodine, in 3 per cent, solution, painted on 
the skin about the closed eyes and on the eyelids themselves, 
where plastic operations are to be performed, is a most effi- 
cient antiseptic, and is to be recommended. After a plastic 
operation if a light coat of this solution is painted over the 
sutures it furnishes an added protection against stitch 
abscess.. 

Further, where stitch abscesses have formed, with re- 
moval of the stitches and an application of a 3 per cent, 
solution of tincture of iodine, we have the best method of 
preventing further infection. 

Asepsis is surgical cleanlinessi. After a wound is made 
the greatest care must be exercised to keep it clean and free 
from germs. This may be done during or immediately after 
the operation by irrigating the operated surface with some 
sterile solution, a plain, sterile water or boracic acid solu- 
tion. After the operation sterile dressings are applied, and 
at subsequent dressings the same care in asepsis must be fol- 
lowed until the wound is entirely healed. If the wound 
becomes infected from any cause, antiseptic solutions may 
be required to cleanse it, but they should not be strong 
enough to produce any sloughing of the tissue. Where 
wounds are septic from the beginning, as in abscesses, 
antiseptic solutions must be used until the wound is free 
of pus. 

9 



130 



EYE NURSING. 



Arrangements for Operations. 

Operating Boom. — If in a hospital, it should be made 
antiseptically clean, of course, as for a general surgical op- 
eration. The operating table should be placed near a win- 
dow in order to get side light, if daylight is to be used. If 
artificial light is to be employed, the table is to be placed 
near and to the side of the source of light. Light coming 
from above, as 1 from a skylight, is bad for operations on the 
eye, as it casts confusing shadows on the field of operation. 
If the operation is to be performed in a private house, the 
nurse may have to improvise an operating table, as a lounge, 
library table, kitchen table, etc. On this table should first 
be placed blankets, over this a rubber sheet, and over this a 
cotton or linen sheet. The pillow should be covered with a 
piece of rubber sheeting and over this an antiseptic towel 
may be spread. Near the operating table and on the side 
opposite from the light should be a small table to hold the 
instruments, tray, dressings, solutions, towels, etc. This 
table should be washed with soap and water and an anti- 
septic solution, and finally antiseptic towels spread on the 
top of it. A second small table may be necessary to help 
hold the dressings and solutions. In hospitals one small 
table made of iron and glass and having two shelves is quite 
sufficient. If a general anesthetic is to be given a small 
table should be provided to hold the anesthetic, inhaler, 
tongue forceps, mouth-gag, hypodermic syringe, solution of 
nitroglycerine, whisky, camphor, nitrate of amyl, a pus 
basin for vomited matter, pads of sterile gauze or towels for 
wiping the patient's mouth, and a galvanic battery. All 
hangings and articles of furniture unnecessary for the op- 
eration should be removed from the operating room. This 
is meant especially in private houses, since in regularly ap- 



STERILIZATION OF INSTRUMENTS. 



131 



pointed operating rooms unnecessary articles of furniture 
are not permitted. It is always to be remembered by the 
nurse that the operating room should be ay arm, from 76° to 
80° F., especially where a general anesthetic is to be given, 
as the patient is lightly clad and entirely relaxed while 
under the anesthetic. The room should be well ventilated. 

Instruments. — In all well-regulated hospitals there 
are dusixproof, air tight, iron and glass instrument cases 
with convenient shelves and racks for holding instruments 
and ligatures. It is the nurse's duty to keep the instru- 
ments clean, dry, and well arranged in these cases, and be- 
fore an operation it is necessary for her or a house surgeon 
to pick out the necessary instruments for the operation. If 
knives, knife-needles, or keratomes are to be used, a test- 
drum should be convenient and handed to the assistant or 
the surgeon to test the sharpness of the instruments before 
they are sterilized. 

Eye instruments are so small and delicately made, 
especially knives, knife-needles, and fine-pointed scissors, 
that they are often dulled or ruined by the nurse in hand- 
ling and sterilizing them, unless she has had special direc- 
tions and warning in the matter, and I speak feelingly on 
the matter, having suffered both in temper and pocket from 
such source. The larger instruments., as speculum, enucle- 
ation scissors, tenotomy hooks, needle-holders, etc., may be 
boiled for from four to five minutes in a 1 per cent solution 
of soda, or they may be sterilized by steam. After taking 
the instruments from the boiling water or steam they are 
placed in a 3 per cent, solution of carbolic acid for five 
minutes, then rinsed in sterile water and placed in an in- 
strument tray or rack ready for use near the operating 
table, a sterile towel being spread over them. Or, after 
boiling, the instruments may be placed in a 1 per cent, solu- 



132 



EYE NURSING. 



tion of cyanide of mercury for five minutes before use. 
Some surgeons prefer to have the instruments dipped in 
alcohol (95 per cent, pure) immediately after boiling, which 
dries them quickly. Cataract knives, keratomes, and knife- 
needles should only be dipped; into boiling soda solution 
(1 per cent.) for about one minute, placing them in racks 
or holding them with forceps and not allowing the instru- 
ments to touch the sterilizing basin for fear of dulling 
them. They are then dipped into alcohol for one minute, 
rinsed in sterile water, and placed in special trays or racks, 
ready for use, being careful not to touch the blades on the 
rack or tray. Some surgeons prefer to have these finer in- 
struments simply dipped in 95 per cent, pure alcohol and 
dried just before using, while others have them dipped in 
boiling water only and dried just before using. 

Soft, sterile gauze or soft, old linen should be used for 
drying instruments, and not cotton, aa is sometimes done. 
If cotton is used, fine shreds are apt to cling to the instru- 
ments and be introduced into wounds or into the eyeball 
itself. Needles should be stuck in a piece of gauze before 
being put into the sterilizer to prevent their being lost. 

Instruments with ivory handles should not be boiled, 
but dipped into boiling water just for a moment, then im- 
mersed in a 5 per cent, solution of carbolic acid for five 
minutes, and dried with sterile gauze. 

Syringes may be sterilized by soaking in carbolic solu- 
tion, 5 per cent., for twenty minutes, then boiling water 
drawn into them and emptied several times to have them 
ready for use. 

Immediately after operation, cataract knives and kera- 
tomes should be dipped into boiling water and cleansed, 
then into alcohol, dried, and placed back in the case. The 
teeth and catches of forceps, joints of scissors and needle 



STERILIZATION OF DRESSINGS. 



133 



holders, needles, and cystitomes should be cleansed in a hot 
1 per cent, soda solution and with especial care, a fine brush 
being used for this purpose. They are then dipped into 
alcohol, dried, and put away. 

Dressings. — Bandages, eyepads, cotton and gauze 
sponges (mops), gauze and gauze strips, towels, and gowns 
for the surgeon and attendants are best sterilized by steam. 
Several sterilizers for this purpose have been invented, one 
of the best being that of Schimmelbusch. In this there is 
a compartment below for boiling the instruments and com- 
partments above for sterilizing dressings by means of the 
steam. It takes but four or five minutes to sterilize the in- 
struments, but the dressings should be allowed to steam for 
at least one-half hour. The large hospitals have hot-air 
sterilizers, in which towels, bandages, dressings, gowns, 
etc., are sterilized at a temperature of 300° F. for the 
space of one hour. For private use, the Eochester combina- 
tion sterilizer shown in Fig. 12 is excellent. It is very much 
like the Schimmelbusch sterilizer, and any of the three 
sterilizing agencies, dry heat, steam, or boiling water, may 
be utilized at will. The sterilizing chamber, by the simple 
turning of a valve, may be filled with either steam or hot 
air, and in this way instruments or dressings may first be 
subjected to dry heat, then steam, sterilized, then thor- 
oughly and quickly dried by hot air. The apparatus con- 
sists of a double-walled chamber. The outer wall rests in 
the groove of a removable base, which forms a water- joint. 
This base may be used for sterilizing instruments with boil- 
ing water (1 per cent, soda solution), if desired, and dress- 
ings, gowns, etc., may at the same time be steam sterilized 
in the chamber above. With the sterilizer there are two 
removable wire-cloth racks: one for dressings, the other 
for instruments. The instrument rack is built to fit either 



134 



EYE NURSING. 



the chamber or base. The Rochester combination sterilizer 
is made in various styles and sizes for both hospital and 




Fig. 12. — Combination Hot Air, Hot Water, and 
Steam Sterilizer, 



physicians' use, and special sizes are made to order. The 
bottom is heated by means of a stove, spirit lamp, or gas 
jet. The apparatus is very simple, efficient, and cheap, and 



DISINFECTION. 



135 



can be carried easily in the hand. A most convenient 
sterilizer for the office is the small electric one; especially 
useful for sterilizing droppers, probes and instruments for 
minor operations. 

Suture Material and Ligatures. — Silk is the most 
common suture material used in operations about the eye, 
and this is usually the iron-dyed, so that the stitches can be 
readily seen when it is time for their removal. Occasion- 
ally catgut is used, but this comes sterilized ready for use. 
For that matter, silk sutures most often come in tubes or on 
spools in bottles, sterilized ready for use. Silk sutures may 
be sterilized by dry heat, one hour, or simply by boiling for 
a few minutes in 1 per cent, soda solution, or in a solution, 
1 to 1000, of bichloride of mercury. A small glass spool or 
reel is convenient for wrapping the silk on while sterilizing. 
After sterilization the material is kept in small bottles im- 
mersed in alcohol until ready for use. 

All dishes, trays, racks, bowls, etc., intended for hold- 
ing instruments and dressings, should either be boiled for 
ten minutes or boiling water poured over them and in them, 
then rinsed in carbolic solution (1 to 20) and dried with a 
sterile towel. Bottles, droppers, and receptacles- intended 
for solutions may be sterilized in the same manner. The 
solutions themselves intended for use in the eye, except the 
antiseptic solutions, must be sterilized before use. Solu- 
tions of cocaine, atropine, eserine, etc., should be made 
sterile by boiling, if not sterilized by the apothecary when 
compounded. This may be done by placing the solution in 
the Stroschein flasks, already described on page 92 and 
boiling for two or three minutes, not longer, when, after 
cooling for a few moments, the solution is ready for use. 
If these flasks are not convenient, an ordinary test tube 
may be used to boil the solution in ; or the original bottles 



136 



EYE NURSLNG. 



may be unstopped, set in a basin of boiling water, and boiled 
for five minutes. 

The Nurse's Hands. — Just as the hands of the sur- 
geon and attendants must be made thoroughly aseptic before 
an operation, so must the hands of the nurse. This may be 
accomplished in one of several ways. As a preliminary 
measure in every instance, the nails should be cut short, and 
carefully cleansed with a nail-file. The method of disin- 
fection may then proceed. One commonly followed by 
many of the surgeons at the New York Post-graduate Hos- 
pital is as follows : ( 1 ) the hands and arms are first thor- 
oughly scrubbed with soap and water with a brush; (2) 
dipped into alcohol (95 per cent.) for one minute; (3) 
dipped into permanganate of potash solution (2 per cent.) 
for from three to five minutes; (4) bleached in a saturated 
solution of oxalic acid until all the stain from the perman- 
ganate is gone ; ( 5 ) dipped into a solution of bichloride of 
mercury (1 to 1000) for one minute. The hands are then 
dried with a sterile towel. A thorough scrubbing of the 
hands with soap and water and brush, and immersing the 
hands in a solution (1 to 1000) of bichloride of mercury 
for ten minutes, is quite sufficient, as a rule, for complete 
asepsis. Some surgeons are very careful in regard to the 
nails, and depend for sterilization of the hands upon scrub- 
bing them very thoroughly with soap and water and brush, 
using no other antiseptic. 

Preparing the Patient. — In all major operations, 
whether a general anesthetic is to be given or not, the pa- 
tient should have a cathartic given the night previous to the 
operation, to be followed the next morning by a saline or 
enema if not effective. If the operation is to be performed 
at a hospital, the patient should be sent to the hospital the 
night previous to the operation to get accustomed to the 



PREPARING THE PATIENT. 



137 



bed and surroundings. A full bath should be given the 
morning of the day of the operation. Just before the pa- 
tient is brought to the etherizing or operating room the day 
clothes should be changed for nightclothes, over which a 
bathrobe or dressing gown is to be worn until the patient is 
placed on the operating table, when he should be covered 
warmly with a blanket. Special inquiry as -to artificial teeth 
should be made, and the patient should be instructed to 
empty the bladder just before going on the table to avoid 
involuntary micturition. Where chloroform is given, the 
lips and nose should be greased with vaseline or cold cream 
to prevent blistering. Patients who are to have a general 
anesthetic given should have nothing to eat on the day of 
the operation, and not until some hours after the operation, 
and then only fluid diet, as tea, milk, and broth in small 
quantities at a time. This precaution on the part of the 
nurse is very important, because with solid food in the 
stomach vomiting is almost sure to come on during or im- 
mediately after the operation, and the patient's life is en- 
dangered from having some of the food lodged in the larynx. 
Furthermore, the success of the operation is greatly im- 
periled, especially if the eyeball has been opened. Even 
the contents of the eye may be extruded, if the vomiting is 
very violent, and the sight totally destroyed. In weakly 
patients a little clear broth or stimulant may be given three 
hours before the operation, but no solids under any circum- 
stances should be given within the six hours preceding the 
operation. 

The surgeon himself or an assistant makes a physical 
examination of the patient as to the heart, lungs, intestinal 
tract, some time before the operation ; and also gives direc- 
tions to the patient as to looking "up" or "down" just before 
the operation is begun. 



138 



EYE NURSING. 



Field of Opmlatton. — In case the operation is on or 
near the eyebrow, this should be shaved before the patient 
is brought to the operating room. Placed on the operating 
table, the patient is covered with a blanket, and over this 
and well up under the chin is placed a rubber sheet. Towels 
should be laid over the pillow of the patient and over this a 
rubber sheet. On the patient's head is adjusted a sterilized 
rubber cap or towel to effectively keep the instruments and 
hands of the operator from contact with the hair. The skin 
about both eyes and the outer surface of the lids is now 
washed thoroughly with soap and water, the edges of the 
lids and eyelashes receiving special care. The skin surface 
may then be mopped in turn with alcohol and a solution of 
bichloride of mercury, 1 to 5000. The lids are now everted 
and the eye and culs-de-sac thoroughly flushed with warm 
sterile water or boracic acid solution squeezed from a pled- 
get of cotton. Some operators wrap a little cotton on a 
cotton carrier, saturate it in the sterile water pr boracic 
acid solution, and carry it along the cul-de-sac above and 
below to insure complete cleanliness. Some surgeons irri- 
gate the eyes and culs-de-sac by means of a small rubber 
bulb fitted to a glass pipette, or the ordinary irrigation 
bottle with rubber tubing and a flattened glass tip is em- 
ployed. In each instance the flattened glass tip is placed 
deep into the cul-de-sac (but the lids not everted) and the 
solution forced out of the rubber bulb gently; or allowed 
to flow out of the irrigation bottle for a few seconds. If this 
is used, care must be taken that the bottle should not be 
placed too high above the patient's head, lest the pressure 
be too great. Other surgeons direct that the nurse or 
assistant wash the eyes thoroughly the day before the opera- 
tion, and bandage the eyes, which bandage is left on until 
just before the operation. 



THE DIFFERENT OPERATIONS. 



139 



Unless there is some mucous discharge from the con- 
junctiva, no antiseptic solutions should be used on the eye 
itself as they are quite irritating ; and, if there is any con- 
siderable discharge from the conjunctiva or lacrymal sac, 
no operation with a view of opening the eyeball shoiild be 
undertaken until this discharge has been relieved by means 
of appropriate treatment, In case of septic operations, as 
abscess, antiseptic solutions may be used on the eye, such 
as bichloride of mercury solution, 1 to 5000, or formalin, 
1 to 5000. The nurse will rarely be called upon to prepare 
the field of operation, most surgeons preferring to do this 
themselves or to have an assistant do it ; but she may, and 
should be able and ready to do it as directed. 

The anesthetic, if general, is usually administered by 
an assistant, but the nurse is occasionally called upon to do 
this in emergency cases. 

Local anesthesia, described in a previous chapter, is 
produced by means of cocaine and holocaine, and is begun 
five to ten minutes before the operation begins, the nurse 
usually putting the first drop in the eye in the anteroom. 
The eye not to be operated upon, after cleansing, should 
have 1 drop of cocaine in it and a pad of moist cotton 
placed over it, This keeps the eye quiet, and the patch pre- 
vents the patient seeing every motion of the surgeon or 
assistants. And this leads me to remark that but few 
spectators should be allowed in the operating room, and 
entire silence must be insisted upon. I suppose it is un- 
necessary to say that nurses and assistants should not 
speak unless spoken to. 

The Different Operations. 
After preparing the operating room, table, instru- 
ments, dressings, and the patient for operation, it is the 



140 



EYE NURSING. 



nurse's duty to assist in the different operations, and to 
care for the patient and to assist in the dressings after the 
operation. The operations upon the appendages of the eye, 
lids, and lacrymal apparatus will be considered first, and 
later the operations upon the eyeball itself. 

In the minor operations, such as opening styes, open- 
ing and curetting chalazia, and passing lacrymal probes, no 
special preparations are required. For a stye all that is 
necessary is a bowl of hot boracic acid solution and a small 
bistoury, which should be sterilized. For a chalazion are 
required hot boracic acid solution, a small bistoury, chala- 
zion curette, 4 per cent, sterilized solution of cocaine, and 
a hypodermic syringe sterile ready for use. The eye is 
washed with boracic solution. A few drops of a 4 per cent, 
solution of cocaine are dropped on to the mucous surface 
of the everted lid. After five minutes the lid is again 
everted and from 2 to 4 drops of a 1 per cent, solution of 
cocaine injected into the tumor by the surgeon. After 
eight minutes' wait the cyst can be opened and curetted 
without the least pain. The after care of styes and chalazia 
may be attended to by the patient himself, and consists in 
bathing the eye with hot boracic acid or salt solution. 

OPERATIONS ON THE TEAR-PASSAGES. 

For slitting the canaliculi and passing probes are re- 
quired hot boracic acid solution, and, if pus is present, hot 
bichloride of mercury solution (1 to 5000), a tube of 
vaseline, cocaine, 4 per cent, solution (except in children 
and weakly patients, when a general anesthetic is given), a 
lacrymal knife, a full set of lacrymal probes, and where an 
abscess is present, a bistoury. All of the above are to be 
made surgically clean, of course. Except in the cases 



EXPRESSION; GRATTAGE. 



141 



where a general anesthetic is given, such cases require no 
special preparation, and are operated on in the outdoor de- 
partment of hospitals and in the private office. 

EXCISION OF THE LACRYMAL GLAND ; THE LACRYMAL SAC ; 

THE PLASTIC OPERATIONS ON THE EYELIDS, AS FOR 
ENTROPION (TURNING INWARD OF THE LH)), ECTRO- 
PION (TURNING OUTWARD OF THE LH>), AND PTOSIS 
(DROOPING OF THE UPPER LID) . 

These operations are usually performed with the pa- 
tient under a general anesthetic. Here the patient must be 
prepared for the anesthetic and all arrangements for an 
antiseptic operation complied with. Antiseptic and sterile 
solutions are to be prepared, bichloride, carbolic, sterile 
water, plenty of hot water, absorbent cotton, pledgets or 
balls of cotton for sponging, bandages, gauze, strip gauze 
(plain and iodoform), iodoform and iodol powder, and the 
following instruments more or less varied according to the 
direction of the surgeon : a Beers knife, bistoury, scissors 
(straight and curved), fixation forceps (small and large), 
dressing forceps, retractors, hard rubber spatula, needle 
holder and needles, sutures, etc. 

EXPRESSION; GRATTAGE. 

The "expression" and "grattage" operations for tra- 
choma are both performed under general anesthesia. After 
the patient is prepared the only instruments necessary in 
the first operation are two pairs of expression forceps, and, 
for grattage, a multiple knife and a stiff toothbrush. Solu- 
tions of hot, sterile water and bichloride of mercury ( 1 to 
500) should be prepared; also plenty of cotton mops for 
sponging, a tube of vaseline, dressings, and a bandage. 



142 



EYE NURSING. 



Some operators put no dressing on the eyes after these 
operations, but have the nurse apply iced cloths frequently, 
thirty minutes at a time, for two or three days. The eyes 
are to be kept thoroughly cleansed with boracic acid solu- 
tion several times a day, and when the surgeon comes to 
examine the case a stiff conical pointed probe (No. 8 Theo- 
bald lacrymal probe is excellent) should be at hand, with 
which he separates the folds of conjunctiva in the culs-de- 
sac. This is necessary because of the adhesions which take 
place after the above operations. A membrane forms on the 
lids within forty-eight to seventy-two hours after the above 
operations. The lids should be everted, if not too much 
swollen, and this membrane gently rubbed away with cot- 
ton wrapped on an applicator. This maneuver should be 
repeated daily until the adhesions and membrane cease to 
form. 

TENOTOMY AND ADVANCEMENT. 

Many times these operations are performed under a 
general anesthetic, especially in children, when the patient 
must be prepared in the usual way. When cocaine is used 
it is generally in 4 to 6 per cent, solution. The instru- 
ments necessary are: speculum, two fixation forceps (nar- 
row and broad), and for the advancement operation some 
surgeons have a special forceps to hold the cut muscle 
(Prince, Eeese), two tenotomy hooks, curved and blunt- 
pointed scissors, needle holder, and threaded needles. 
Solutions of boracic acid, or plain sterile water, oval 
patches of gauze and cotton, a roller bandage, and pledgets 
of cotton for sponging, complete the arrangement for the 
operation. During the operation the nurse will have little 
to do. Most surgeons in America bandage the eyes for 
from twelve to twenty-four hours, and some for four or 



ENUCLEATION. 



143 



five days, changing the dressing daily. After the first day 
iced cloths are usually applied, three or four times a day, 
and the eye kept clean with boracic acid or other bland 
solution. 

OPERATIONS ON THE EYEBALL WHEN THE EYE 
IS NOT OPENED. 

Corneal ulcers are sometimes curetted, and then 
cauterized with pure carbolic acid (95 per cent.). The 
nurse should get ready a 4 per cent, solution of cocaine, a 
small curette, carbolic acid, a gauze pad, and bandage. 
Sometimes the actual cautery is used, when a spirit lamp 
and blunt-pointed probe are to be ready. Often the surgeon 
uses a Paquelin cautery or the galvanocautery ; a solution 
of atropine (gr. iv to §j) should be at hand. 

ENUCLEATION. 

The patient must be prepared for a general anesthetic. 
The instruments required are large and small blunt- 
pointed, curved scissors, two fixation forceps, a tenotomy 
hook, and a speculum. In case of exenteration of the orbit 
a periosteum elevator must be had also. Solutions of bi- 
chloride of mercury, 1 to 5000, and boracic acid, saturated, 
and very hot water should be ready, also cotton sponges, 
plain, sterilized gauze in pads, and iodoform gauze and 
plain sterilized gauze in strips and bandages. In case of 
much bleeding the orbit is douched with hot boracic solu- 
tion, or plain hot water, the orbit packed tightly with strip 
gauze, and a firm bandage applied. Should bleeding come 
on some time after the operation, the nurse should apply 
a bandage tightly over the other bandages, and if this does 
not control the bleeding the dressing should be removed, 



144 



EYE NURSING. 



the orbit washed with very hot boracic acid solution, packed 
tightly with gauze, and rebandaged tightly. Of course, this 
must be done under strict antiseptic conditions, and the 
surgeon notified. Sometimes great difficulty is encountered 
in removing the first packing from the orbit after an 
enucleation or exenteration. 

If necessary, this packing should be soaked with hot 
boracic acid for half an hour rather than cause the patient 
great pain. This is done by removing the outer dressing 
and squeezing a small stream of the boracic acid solution 
from a pledget of cotton, holding the lids apart with the 
other hand. The dressings are changed daily for four or 
five days, when they may be discontinued, and an artificial 
eye introduced at the expiration of one week or ten days. 

In the Mules operation, a substitute for enucleation, 
the front of the eye (cornea) is cut off; the contents 
curetted out to the sclera; a glass, silver, paraffin, or gold 
ball inserted, and the wound closed with many sutures. 
Fat from the patient's own body may be used to fill the 
cavity of the sclera. The additional instruments required 
are a Beer's knife or small scalpel, straight scissors, Mules's 
instrument for inserting the balls into the sclera, a sharp 
curette, glass or silver balls, and several threaded needles. 
Carbolic acid (95 per cent.) and alcohol (95 per cent.) 
should be provided. The strictest antiseptic precautions 
are necessary in this operation. Some American surgeons 
apply a firm bandage for twelve hours, followed by iced 
cloths, while others begin the application of iced cloths 
shortly after the operation. There is always intense re- 
action following this operation, redness of the lids; 
chemosis of the conjunctiva, protruding between the lids at 
times; redness, pain, and often rise of temperature. 

The patient is always put to bed after an enucleation 



NEEDLING OPERATION. 



145 



or Mules's operation, is given fluid diet for twenty-four 
hours, and the temperature and pulse are charted at least 
twice a day. 

OPERATIONS WHERE THE EYEBALL IS OPENED. 

It may be stated here that in all operations where the 
eyeball is opened the strictest antisepsis and asepsis must be 
practised. Even in the simple operations of paracentesis 
and needling (keratonyxis) , where but one or two instru- 
ments are used, just the same care must be exercised as in 
preparing for a cataract extraction. Tepid, sterile water 
and boracic acid solutions are the best for cleansing the eye 
where the eyeball is to be opened. Bichloride of mercury 
solution certainly should not be used after the eye is once 
opened, as it tends to cloud the cornea. 

PARACENTESIS. 

The instruments necessary for this operation are a 
narrow Graefe knife, a speculum, and fixation forceps. 
W arm boracic acid solution, 4 per cent, solution of cocaine, 
patches of gauze and cotton for each eye, a bandage, and 
narrow strips of adhesive zinc oxide plaster are to be made 
ready. 

NEEDLING OPERATION. 

For a needling operation, a knife-needle, fixation for- 
ceps and speculum, in addition to warm, sterile, boracic 
acid solution and dressings for.each eye and a bandage, are 
required. In removing thick membranes from the pupil 
(membranous cataracts) it is necessary to open the eye as 
for iridectomy. The instruments required are : a speculum, 
fixation forceps, angular keratome, iris scissors, iris forceps, 

10 



146 



EYE NURSING. 



and a narrow spatula or iris replacer. The pupil should be 
dilated with atropine before the operation, and a solution of 
atropine (gr. iv to should be at hand for instillation 
immediately after the operation. Dressings for both eyes 
and a bandage are necessary. 

SCLEROTOMY. 

For sclerotomy, the instruments required are a cataract 
knife, fixation forceps, and speculum ; and iris forceps and 
scissors may be needed, so should be ready. The same solu- 
tions and dressings are necessary as for the needling opera- 
tion. 

IRIDECTOMY. 

For iridectomy, the same solutions and dressings are 
necessary as for sclerotomy, but more instruments are re- 
quired. In addition to the speculum, fixation forceps, and 
narrow spatula (iris replacer), an angular keratome is usu- 
ally preferred to the Graefe knife; iris forceps and iris 
scissors are also needed. After sclerotomy or iridectomy is 
performed for glaucoma a sterile solution of eserine (gr. ij 
to ^j) or pilocarpine (gr. iv to %]) should be on hand for 
instillation into the eye immediately after the operation. 

OPERATION FOR EXTRACTION OP SENILE CATARACT. 

The patient should be sent to the hospital the after- 
noon previous to the day of the operation, that the patient 
may become accustomed to the bed and surroundings, the 
bowels opened with a cathartic, and the morning of the day 
of the operation a general bath given. If a general anes- 
thetic is to be given, which is rarely the case, the patient 
should fast for at least six hours before the time for the 
operation. Even where cocaine is employed as the anes- 



EXTRACTION OF SENILE CATARACT. 



147 



thetic, which is usually the ease, the stomach should be 
empty or only liquid food given, and this not nearer than 
three hours before the operation. Vomiting may be caused 
by the shock of the operation, and a full stomach may be 
put down as a predisposing cause. Of this I have had sad 
experience hi one case of cataract extraction at a private 
house. The lady was given the usual instructions as to the 
bath and cathartic the night previous to the operation, and 
was told to eat a very light lunch at 12 o'clock (operation 
to be at 3 p.m.). Instead of eating a light lunch she ate 
very freely and took some brandy to fortify her nerves. 
Immediately after the extraction, and before the bandage 
could be applied, she began to vomit, continuing for some 
half-hour, the bandage being applied in the meantime as 
well as possible. On inspecting the eye 'the next day the 
retina was found detached and protruding from the wound. 
I cite this case to emphasize the necessity of taking every 
precaution to insure quiet and rest during and after the 
operation in cases where the eye is to be opened. The in- 
struments required are : speculum, fixation forceps, G-raefe 
cataract knife, cystitome, Daviel spoon, shell spoon, iris 
replacer or spatula, wire spoon or vectis, iris forceps, and 
iris scissors. Some surgeons have in readiness also a suc- 
tion syringe (Teale's) or irrigating tube (Lippincott's), in 
case of much cortical matter, to assist in its. removal. 
Warm solutions of boracic acid (saturated), sterile water, 
normal salt solution, and a 4 per cent, solution of cocaine, 
all sterile, should be freshly prepared. Cotton balls for 
sponging, oval eyepads (cotton between layers of gauze), 
bandage, strips of adhesive zinc oxide plaster, and eye- 
shield (Ring's) should be in readiness. The instruments 
should be on a tray by themselves, while the dressings 
should be on a separate tray. A double-shelved table may 



148 



EYE NURSING. 



hold both and the necessary solutions, or a second small 
table may be required. Just before and during the opera- 
tion the nurse should be ready to hand the surgeon the 
cocaine solution, or bowls containing the cleansing solu- 
tions, cotton balls, etc. Immediately the section is made, 
the knife should be taken in charge by a nurse and cleansed 
and dried, not allowing it to be knocked about with the 
other instruments. After the operation the nurse is to 
hand the tray with the dressings to the assistant, and, when 
both eyes are bandaged (even if but one is operated on) 
and the shield applied, is to assist in getting the patient off 
of the table and into the bed with the least possible strain- 
ing or jarring of the patient. In bed the patient is to be 
placed on his back, or on the side opposite to that operated 
upon, quiet enjoined, and the patient warned not to pick 
at the dressing or to move for anything whatsoever, but to 
call the nurse when anything is wanted. In a private case 
the nurse will be by the patient's side most of the time, but 
in a ward an electric push bell, the handle of which is at- 
tached by a cord to the bed and the patient's hand placed 
on it to show him where it is, serves to call the nurse for 
every want, as for a drink, to turn in bed, the urinal or 
bedpan, etc. 

In the author's opinion it is a good plan to give the 
patient an opiate the first night following a cataract extrac- 
tion. This usually assures a good night's rest and en- 
hances the chances for smooth and early healing of the 
wound. 



CHAPTER IX. 



AFTER-NURSING OF THE DIFFERENT OPERATIONS 
ON THE EYE. 

Plastic Operations — Operations on the Eyeball — Operations 
where the Eyeball is Opened: Paracentesis; Needling; Sclerot- 
omy; Iridectomy; Extraction of Senile Cataract — Complications: 
Delayed Union of the Wound; Infection; Iritis; Entropion; 
Shock; Vomiting; Delirium. 

It is in the management of cases after operations, 
especially in private cases, that the ability and capability of 
the nurse is thoroughly tested. In carrying out instruc- 
tions she must be resourceful, but tactful ; gentle, but firm ; 
never losing her temper, but ever patient, bearing in mind 
always that she is dealing with sick people. Truly efficient 
nurses, like poets, it may be said, are born, not made. 
Training may do wonders for her as far as arranging for 
and assisting at operations and nursing in a hospital ward, 
but for private nursing, to be successful, there must be an 
innate aptness not furnished by any amount of training. 
Many nurses, in fact, shrink from this work just on account 
of the difficulty of "managing" such patients. 

Plastic Operations. 

In the various plastic operations upon the eyelids and 
especially where a general anesthetic has been given, the 
nurse is to accompany the patient to the ward or private 
room, as the case may be, and remain by the bedside until 
the patient is out from under the influence of the anes- 

(149) 



150 



EYE Nl EtSING. 



thetic. In cases of children who have a tendency to pull 
off the dressings their hands should he tied to the sides 
of the bed. Unless there is some complication, as shock, 
hemorrhage, vomiting, etc., which will be spoken of later, 
the nurse's chief duty for the first twenty-four to forty- 
eight hours is to see that the patient gets the proper diet at 
the right time and sufficient rest and is not allowed to 
suffer too much pain. Where both eyes are bandaged, the 
patient must be fed by the nurse and assisted with the 
urinal and bedpan, unless the patients are able to walk, 
when they are to be led to the closet and back to the ward 
or room. After a general anesthetic no solid food should 
be given for at least four hours, but hot soups, broth, or 
milk may be given in limited quantity, and a little at a 
time, two hours after the operation, and repeated in from 
one-half to one hour if the first amount is retained. There 
should be no hurry about feeding the patients after an 
operation, even with "slops" unless the patient is very weak. 
. The nurse should also be very careful how she gives water 
to patients shortly after general anesthetics have been ad- 
ministered, although the patients may be very thirsty. The 
best plan is to let them suck small pieces of ice. After the 
first twenty-four hours semisolid food may be given, as 
eggs, oatmeal, and mush; and after forty-eight hours usu- 
ally a solid diet may be given, unless there is some contra- 
indication, in which case the surgeon directs just what is 
to be given and what not. The pulse and temperature 
should be charted for a few days, especially when there is 
any febrile reaction. The bowels should move on the 
second day after the operation. 

In all redressings following operations the nurse is. to 
be just as careful in her antiseptic and aseptic methods as 
when preparing for the operation. In the first place, all 



AFTER EXTRACTION OE CATARACT. 



151 



bowls, basins, solutions, and dressings must be strictly asep- 
tic, as must also all dressings, forceps, or other instruments 
to be used in redressing the cases and for removing stitches. 
And, of course, the nurse's and the attendant's hands must 
be aseptic. 

The after-nursing of operations upon the eyeball where 
the anterior chamber has not been opened has been indi- 
cated already in Chapter VIII under the description of the 
different operations themselves, and need not be repeated 
here. 

Operations where the Eyeball has been Opened. 

In simple paracentesis of the cornea the after-care is 
usually very simple. The wound, being small, is healed at 
the first inspection. Of course, all antiseptic and aseptic 
precautions are to be observed in redressing the wound. 
Two or three dressings, consisting of an oval gauze and 
cotton pad, held in position with strips of plaster, are all 
that are required. 

The ' needling operation for membranous cataract 
following the extraction of a senile cataract, if no complica- 
tions ensue, requires but little after-care. The eye is in- 
spected daily after the operation, the dressings (patch and 
adhesive strips) changed under strict antiseptic precau- 
tions, and a drop of a solution of atropine (gr. iv to 53) is 
instilled. The patient may be confined to the house for 
four or five days before being discharged. Usually smoked 
classes are worn for a few days, if the eye is sensitive to 
light. Where needling is done to remove soft cataract in 
the young, the eye is inspected daily, the dressings changed 
under strict antiseptic precautions, and a drop of atropine 
instilled. If all goes well the patient is ready to leave the 
hospital in five or six days' time. Occasionally after 



152 



EYE NURSING. 



needling a soft cataract the lens swells so rapidly that it 
causes marked plus tension or hardening of the eyeball, ac- 
companied by intense pain in the eye and redness of it; 
that is, it produces secondary glaucoma. Where the pain 
persists: and the tension of the eye remains much elevated, 
the surgeon usually performs linear extraction of the soft 
cataract, for which see below. 

After the operation of sclerotomy and iridectomy usu- 
ally both eyes are bandaged, and the patient put to bed for 
a few days and fed on slops for the first day. Great care is 
taken to prevent the patient from straining or exerting 
himself in any way. The eye is inspected under the strict- 
est antiseptic precautions daily, and the dressings reapplied. 
If the operation has been performed for the cure of glau- 
coma, as is often the case, a sterile solution of eserine (gr. 
ij to §j) or of pilocarpine (gr. iv to 5j) should be in readi- 
ness to be instilled at each dressing. 

After-care of Operations for Senile Cataract. 

The after-treatment of cataract operations varies some- 
what with different surgeons. As a rule, however, both eyes 
are closed after the operation with oval cotton or cotton- 
wool pads, inclosed between a single layer of gauze on either 
side of the cotton, which are held in position with narrow 
strips of adhesive zinc oxide plaster. Over this, most 
ophthalmic surgeons place a roller bandage (of flannel or 
gauze 1% inches wide) to make the dressing more secure, 
and the whole is covered with a shield to prevent injury to 
the eye. Some surgeons use simply the pads held in posi- 
tion with adhesive strips, and over this a protective shield ; 
others have advised a strip of isinglass plaster (1 by 1% 
inches) to close the lids with, and no other dressing ; while 



AFTER EXTRACTION OF CATARACT. 



153 



a few surgeons use no dressing whatever on the eye. In my 
opinion, without question, after cataract extraction, a dress- 
ing of some kind affording support and protection to the 
eye during the healing process should be used. The oval 
pads on each eye, held in position by strips of adhesive 
plaster and protected by a Ring papier mache mask is about 
the best dressing, and I believe it to be a good practice to 
place a bandage over the pads on both eyes before the mask 
is applied. The objection to the bandage that it causes 
"dragging" on the dressings is overcome by strips of adhes- 
ive plaster which hold the dressings (pads) in position. 

The patient is placed in a moderately lighted room 
in bed and on his back or on the side opposite to the eye 
operated upon. He should stay in bed at least twenty-four 
hours, and it is better to have him remain in bed two or 
three days until the wound is healed, after which he may 
be allowed to sit up in an armchair for part of the day, or 
all day, if he is more comfortable sitting up. When con- 
fined to bed the urinal and bedpan should be used. If the 
bowels do not move on the third day after the operation an 
enema of warm water and soapsuds should be given. The 
patient should be cautioned not to strain at stool, as great 
harm can result to the eye as a result. The diet should be 
fluid for the first day, and semisolid the next two or three 
days, after which the usual diet may be given, with care 
not to overfeed, or upset the stomach. Mild stimulants may 
be required in some cases, especially if the patient has been 
accustomed to them. The nurse must feed the patient as 
long as both eyes are bandaged. Highly seasoned foods, 
and fruits and pastries, except in limited quantities, are 
contra-indicated. 

For the first few days after extraction of senile 
cataract there is usually some smarting and burning in the 



154 



EYE NURSING. 



eye and a "sore feeling" complained of, but not a sharp 
or aching pain. This wears off in three or four days' time, 
and the patient is able to rest. If these symptoms continue 
and the patient is unable to sleep an anodyne should be 
given. If a shooting or decidedly hard pain should persist, 
the surgeon should be notified, the dressing removed, and 
the eye inspected and redressed. Sometimes a faultily ap- 
plied bandage, or an eyelash loosened and caught between 
the lids, may cause the pain, or, if a simple extraction has 
been performed, a prolapse of the iris into the wound may 
cause acute pain. Acute persistent pain demands inspec- 
tion of the eye and redressing, even within five or six hours 
after the operation. If all goes well, however, the first 
dressing should not be made until twenty-four hours after 
the operation, some surgeons waiting two or three days be- 
fore making a change. If a simple extraction is done, that 
is, without iridectomy, the dressing should be changed in 
twenty-four hours, and the eye looked at to see if any pro- 
lapse of the iris has occurred. The lower lid is pulled 
gently downward, a little warm, sterile, boracic acid solu- 
tion squeezed from a pledget of cotton into the eye, the 
lower lid and face bathed with the sariie solution, and the 
eye bandaged. The dressings are to be changed daily under 
the strictest antiseptic precautions, especially Until the 
wound is healed. On the third day after the operation, 
most surgeons, instill a drop of atropine into the eye, and 
repeat the instillation daily until the eye is quiet, and white. 
Both eyes are kept closed for five or six days, when the un- 
operated eye is left uncovered and protected by a double 
shade covering both eyes. About the sixth or seventh day 
all dressings may be left off and the eyes protected with a 
shade or smoke -coquilles. From the tenth day the patient 
may be allowed to take a little exercise out of doors. 



LOCAL COMPLICATIONS. 



155 



The foregoing description applies to the normal, un- 
complicated course of healing following extraction of senile 
cataract. Several complications, both of a local and a gen- 
eral nature, may occur to interrupt and retard the healing 
process or even jeopardize the success of the operation 
altogether. 

LO€AL COMPLICATIONS. 

First, the local complications which may ensue will be 
considered in turn ; they are : delayed union of the wound, 
infection of the wound, iritis, deep infection, panophthal- 
mitis, meningitis by extension, pseudo- or false erysipelas 
from atropine, etc. 

Delated union of the wound may result from im- 
proper apposition of the wound surfaces, or from lack of 
nutrition in old or debilitated patients, and at times with- 
out any apparent cause. Where apposition of the wound 
surfaces is not good the surgeon readjusts them, and, in the 
cases due to lack of nutrition, tonics and concentrated 
fluid diet are resorted to. The eye must be kept bandaged 
until the wound closes, even if it is as long as two weeks, 
the dressings being changed infrequently ; that is, at two or 
three days' interval; so as not to disturb the wound any 
oftener than is absolutely necessary. 

Infection of the wound is manifested by pain, lac- 
rymation, and more or less muco-purulent discharge from 
the eye. In such case the simple eyepad held in position 
with adhesive strips and covered with the Eing protective 
shield, which can be removed readily, is the best dressing. 
The eye should be inspected two or three times during the 
day, bathed with hot boracic acid solution, and atropine in- 
stilled. The surgeon usually cauterizes the wound with 
pure carbolic acid, the galvanocautery, or the actual cau- 



156 



EYE NURSING. 



tery, any one of which the nurse should have in readiness 
according to the direction of the surgeon. A local applica- 
tion of a 50 per cent, solution of argyrol has proved of 
great service in some of the cases, and it has the advantage 
of being non-irritating. A 4 per cent, solution of cocaine 
should be ready for producing local anesthesia before cau- 
terization is done. Dusting the wound with iodoform is 
of benefit in some cases. 

Deep infection of the eye may extend from the 
wound infection, or occur within the eye while the wound 
heals. It is manifested by severe pain, cloudiness of the 
aqueous humor, discoloration of the iris, pus in the an- 
terior chamber perhaps, and marked redness of the eye. If 
not checked, the conjunctiva becomes chemotic, the eyelids 
swollen and edematous, all of the tissues of the eyeball be- 
come inflamed, and there is excruciating pain, with intense 
suffering, accompanied by rise of temperature, rapid pulse, 
and at times with vomiting. Cases of death from menin- 
gitis by extension of pus from the eye to the meninges have 
been reported. 

Where infection occurs deep in the eyes, the symptoms 
(which may not be present till the third or fourth day after 
the operation) indicate to the house surgeon that a serious 
complication is taking place. This should be reported at 
once to the surgeon. When certain that infection has taken 
place, the wound should be opened, the anterior chamber 
irrigated with a warm, sterile, salt solution, the edges of 
the wound cauterized, atropine instilled, and hot fomenta- 
tions applied for twenty minutes every two hours. Some 
favorable results have been reported where the infection 
has been checked and the eye saved by injecting a few drops 
of a 25 per cent, solution of argyrol into the anterior cham- 
ber (Webster). Where the inflammation results in a 



LOCAL COMPLICATIONS. 



157 



panophthalmitis (all the tissues of the eye becoming in- 
volved), poultices must be applied, anodynes given, the 
wound opened and irrigated with antiseptic solutions, and 
the patient made as comfortable as possible. 

The nurse will find plenty to do in infected cases in 
keeping sterile solutions and dressings on hand, in cleans- 
ing the eyes, or* assisting, and in making hot applications. 
Antiseptic precautions are to be observed, of course. 

Infection of tbe eye may result from the needling op- 
eration for membranous cataract. In fact, infection is 
more apt to occur after a needling operation than after the 
primary operations, if antiseptic methods are not rigidly 
followed. Germs carried into the eye with the needle 
remain in it, the opening made by the needle being so small 
they cannot easily escape ; whereas, after section of the cor- 
nea, germs, if not too many are introduced, may be washed 
away by the aqueous humor and by irrigation with sterile 
water or boracic acid solution. It is altogether essential, 
therefore, that the needle be absolutely aseptic, and, for 
that matter, all other instruments connected with the deli- 
cate operation for needling. 

Iritis. — This complication may be of a very mild na- 
ture, accompanied with but little or no pain, redness, or 
irritation, yet of sufficient intensity to cause adhesions to 
form between the iris and the remains of the lens capsule. 
To obviate this, most surgeons instill a drop of atropine 
into the eye on the third day after the operation and for a 
few days following. This dilates the pupil and prevents 
the adhesions. 

Severe iritis of an exudative nature sometimes follows 
extraction of senile cataract, especially if the iris has been 
bruised at the time of the operation. It usually manifests 
itself on the third or fourth day following the operation by 



158 



EYE NURSING. 



redness of the eyeball; pain of a severe nature, worse 
toward night; lacrymation ; discoloration of the iris; con- 
traction of the pupil, and an exudate may be thrown out 
blocking the pupil. In such an unfortunate complication 
the nurse will be required to apply leeches to the temple, 
change the dressings several times (three or four) during 
the twenty-four hours, to apply hot, moist fomentations to 
the eye, and at the same time to instill a drop of atropine 
solution (gr. viii-xij to §j) into the eye. The bowels 
should be opened thoroughly with calomel and soda, or 
some other cathartic. At times, sweating the patient freely 
seems to give relief. The patient must be kept on fever 
diet. 

Sympathetic inflammation of the fellow-eye 
may follow the operation for the extraction of senile cat- 
aract, especially if the iris or lens capsule is caught in the 
wound and retained there during the healing process. It is 
truly an unfortunate complication and often results in total 
blindness. Its symptoms and method of treatment have 
been described previously (see page 57). 

Hemorrhage may follow the operation of iridectomy 
for glaucoma, or operation for cataract, and is always a 
most serious complication, the sight many times being lost 
as a result. It occurs most frequently in arthritic patients 
and those with high blood-pressure, usually without warn- 
ing, and little can be done to prevent it. Bleeding may 
take place from one of the iris vessels or from some of the 
deeper vessels in the eye. It has a tendency to occur in 
glaucoma. If a sharp and intense pain strikes the eye sud- 
denly a few hours after the above operations, especially if 
accompanied by nausea and sickness at the stomach and de- 
pression, the nurse should report such facts at once to the 
surgeon or assistant. Eemoval of the 'dressings may show 



GENERAL COMPLICATIONS. 



159 



them to be wet with blood, or the blood may be clotted be- 
tween the lids or in the lips of the wound itself. The 
blood-clots should be removed, very hot wet compresses ap- 
plied for a while, to try to stop the hemorrhage, and a 
compress held firmly with a roller bandage applied. The 
patient may be propped up in bed, perfect quiet enjoined, 
and sedatives may be administered by direction of the sur- 
geon. Whatever is done the eye is usually lost through in- 
fection, or later by shrinkage of the globe. 

Spastic entropion (turning inward) of the lower lid 
is an annoying complication occasionally following opera- 
tions on the eyeball. Painting the skin surface of the lid 
and the face just below the eye with flexible collodion gives 
relief many times. If this is not effective, a stitch placed in 
a vertical direction through the skin of the lid and cheek 
and tied firmly usually gives the desired effect. 

GENERAL COMPLICATIONS. 

Complications of a general nature which may follow 
operations on the eye and its appendages are : shock, 
vomiting, and delirium. 

Shock as a complication after ophthalmic operations 
is rare. It should be dealt with as after other operations, 
the patient put to bed, hot-water bags applied to the feet 
and sides, and stimulants given. 

Vomiting following operations upon the eye where the 
eyeball has been opened is a very undesirable complication 
and one to be avoided if possible. Before the discovery of 
the anesthetic properties of cocaine by Koller, when these 
operations were performed with the patient under the in- 
fluence of a general anesthetic, especially after ether, vomit- 
ing was a frequent complication. Thanks to the genius of 



160 EYE NURSING. 

this great man, we have been given the boon of a local 
anesthetic, after the use of which the patient is freed of 
pain during the operation, and the dangerous complication 
of vomiting made much less frequent than after ether or 
chloroform anesthesia, to say nothing of the danger to life 
from the exhibition of the latter two. 

At the very first indication of sickness at the stomach 
or nausea, the patient should be placed flat on the back, if 
not already in that position, all pillows removed from the 
head, and a mustard leaf applied to the stomach. A tea- 
spoonful of hot water, tea, or coffee sometimes allays the 
trouble, or even a small piece of ice in the mouth may be of 
service. Many, many remedies have been advised for 
vomiting, and any one of these, according to the direction 
of the surgeon, may be given. During the paroxysms of 
vomiting the patient's head should be supported by the 
nurse, taking care not to disturb the dressings any more 
than can be helped. If the dressing should be soiled, the 
outer bandage may be removed and fresh dressings applied. 

Delirium, leading at times into acute mania, some- 
times follows operations upon the eyes, particularly after 
the operation for the extraction of senile cataract and 
iridectomy for glaucoma where both the eyes are bandaged 
and the patient thus placed in total darkness. It is usually 
manifested in from twenty-four to seventy-two hours, but 
it may be four or five days after the operation. The pa- 
tient becomes restless, with inclination to talk, or laugh or 
cry perhaps; sometimes terror or fright seizes the patient, 
and he imagines some one is trying to injure him. With 
such symptoms coming on, the nurse should notify the sur- 
geon at once, and remain constantly by the patient's side 
to prevent him from tearing off the dressings, injuring the 
eye or perhaps himself. In many instances freeing one eye 



GENERAL COMPLICATIONS. 



161 



(the unoperated one) gives entire relief. At times both 
eyes may have to be freed, and if this does not give relief, it 
may be necessary to use force in restraining the patient. 
If in a hospital, the patient should be allowed to return 
home at the earliest possible moment. Sometimes the 
familiar surroundings of home assist in clearing up the 
hallucinations and illusions of the patient. 

Where the patient becomes violent and delusions are 
present, sedatives, such as opium, bromides, etc., should be 
given. Until the wound is entirely healed the nurse must 
be constantly in attendance. 



11 



CHAPTER X. 



DRESSINGS, BANDAGES, SHADES, PATCHES, PRO- 
TECTIVE SHIELDS, PROTECTIVE GLASSES, 
AND ARTIFICIAL EYES. 

Antiseptic Dressings — Bandages — Application of Roller Ban- 
dages — Special Bandages — Masks and Shields — Redressings — 
Shades and Protective Glasses — Artificial Eyes. 

Dressings. 

The nurse will be called upon to prepare many of the 
dressings, bandages, and shades used about the eyes, and for 
that reason should be ready and able to do such work when 
it is necessary. All dressings to be used about the eves 
should be aseptically clean, while some of the dressings are 
rendered antiseptic by being impregnated with antiseptic 
remedies, such as bichloride of mercury, carbolic acid, 
iodoform, etc. Dressings for the eyes are needed chiefly 
after operations upon the eye, to support and protect the 
wound and to keep it free from septic material. They are 
required at times in the treatment of diseases of the eyes. 
For example, in detachment of the retina, the pressure 
bandage is used to promote absorption of the fluid beneath 
the retina. It is also used to promote absorption of in- 
flammatory material in the lids, or to prevent swelling of 
the lids, as after the operation of expression in trachoma, 
or after the Mules operation. Or a dressing may be used to 
support the cornea and prevent its rupture when thinned 
by ulceration; or, when thinned by malnutrition, to pre- 
vent staphyloma or conical cornea, etc. 

The materials of which eye dressings are made are ab- 
sorbent cotton, cotton wool, gauze, or cheese cloth prepared 
(162) 



DRESSINGS. 



163 



in such way that they are absorbent. They may be 
sterilized and used plain or impregnated with some anti- 
septic material, as stated above. 

For convenient use on the eye the cotton and cotton 
wool and gauze are cut into oval pads or patches about 
three inches long by two inches wide. The cotton as it 
comes prepared in the rolls from the druggist is in layers 
of from Y 2 to 1 inch in thickness. • Thin patches may be 
made from a single layer of this, or, if the surgeon wishes, 
they may be made of two layers. On each side of this patch 
of cotton or wool is placed a single layer of gauze of the 
same size as the cotton patch. This prevents the cotton or 
wool fibers from getting into the eye or the wound itself. 
In hospital' operating rooms a great number of these 
patches are prepared, sterilized, and stored in dust-proof 
glass jars. 

Pads of several thicknesses of gauze, cut in the same 
shape and size as the above, are preferred by some surgeons. 
Again, pads of gauze, 8 inches long by 4 inches wide, with 
a notch cut in one edge for the nose, form a very convenient 
dressing when both eyes are to be covered, especially after 
•plastic operations upon the eyelids or about the orbit. Over 
this wide pad is placed loose gauze to level out the depres- 
sions over the orbits so as to give uniform pressure and sup- 
port to the wound. 

For packing the orbit and for drainage purposes, the 
gauze is 1 cut into narrow strips, 1 inch wide by 3 yards long ; 
this may be left plain or it may be impregnated with iodo- 
form, aristol, or other antiseptic remedies. This strip 
gauze is sterilized and packed snugly in test tubes and 
sealed ready for use. 

The best way to sterilize plain dressings is to place 
them in a hot-air sterilizer (temperature, 300° F.) for one 



164 



EYE NURSING. 



hour. The receptacle for storing them may be treated in 
the same manner, or scalded with boiling water and later 
washed with a solution of carbolic acid (1 to 20) and dried, 
when they are ready for use. The bandages for holding 
these dressings on the eye should be sterilized in the hot air 




Fig. 13.— Oval Eye Patch held on by Strips of Plaster. 

at the same time as the dressings. Dressings thus pre- 
pared are thoroughly aseptic, and, except in septic cases, 
are preferable to dressings incorporated with antiseptic 
materials, which latter are apt to prove more or less 
irritating. 

Where the oval eyepads are used, which are the most 
widely employed of all dressings for the eye, they should be 
held in position on the eye by two narrow strips, % inch by 
4 inches long, of adhesive zinc oxide plaster for each pad. 
The strips are put on in a vertical direction extending from 



ANTISEPTIC DRESSINGS. 



165 



the brow down and slanting slightly outward to the cheek 
below (see Fig. 13). This zinc plaster is prepared antisep- 
tically and comes in convenient narrow rolls. Plain, adhe- 
sive plaster should not be employed, as it often causes irrita- 
tion of the skin. Over this pad and strips of zinc plaster a 
bandage should be applied. If the zinc plaster strips are 
not used, the bandage is applied directly over the dressings. 
In my opinion the strips should be used in every case where 
the eyepads form the dressings, for they prevent the pads 
from slipping or becoming displaced and at the same time 
obviate the "dragging" of the dressings by the bandage. 
These two advantages outweigh by far the small disadvan- 
tage and annoyance of removing the plaster. If the pa- 
tient is warned and the plaster gently removed (using a 
little ether if necessary in very nervous or sensitive pa- 
tients, which renders the process absolutely painless) most 
patients do not complain. But, even if they do, a little 
annoyance with the chance of a good result is much to be 
preferred to entire comfort and the risk of a bad result. 

ANTISEPTIC DRESSINGS. 

These are made from the sterilized plain dressings by 
incorporating into them antiseptics of various kinds, as 
iodoform, carbolic acid, bichloride of mercury, or others, 
according to the desire of the surgeon. 

Bichloride Gauze. — Impregnate absorbent gauze 
with a solution of bichloride of mercury 1 to 1000 contain- 
ing 10 per cent, of glycerine. Wring it out, roll it up, and 
put it up in paraffin paper. The addition of the glycerine 
renders the gauze less irritating. It is well to tint the 
solution with fuchsin, as this enables the manufacturer to 
note whether the solution has been distributed uniformly 
throughout the gauze. 



166 



EYE NURSING. 



Iodoform Gauze. — Dissolve 4 parts of iodoform in 16 
of ether. Then add 16 parts of alcohol, 2 parts of tincture 
of benzoin, and 2 parts of glycerine. To make a 10 per 
cent, gauze : weigh out 100 parts of the above solution, 
which contains 10 per cent, of iodoform; also weigh out 
88 parts of gauze, and make the latter absorb the whole of 
the former. On drying, the gauze will retain the 10 parts 
of iodoform and the 2 parts of glycerine, and it will there- 
fore be a 10 per cent, iodoform gauze. 

Carbolized Gauze. — This is prepared in the same 
manner as the bichloride gauze. The strength of the solu- 
tion used should be 1 to 40. 

Borated Gauze. — Saturate the gauze with a 10 per 
cent, solution of boracic acid, made with boiling water. 
Tincture of benzoin is added to this solution to make the 
medicament adhere more firmly to the gauze. It is impor- 
tant to hang the gauze up in a horizontal position, as in 
any other position the solution would be apt to drain off 
unevenly. 

An antiseptic dressing may be made by applying an 
ointment, made from any one of the above remedies, to the 
plain gauze, or directly on the wound. For example, 1 to 
5000 bichloride of mercury vaseline, 10 per cent, iodoform 
vaseline, 1 per cent, carbolized vaseline, or 3 per cent, 
borated vaseline. Or iodoform, aristol, boracic acid, etc., 
may be dusted on the eye or wound and a plain dressing 
put over this. 

BANDAGES. 

The materials for bandages are gauze, flannel, and 
white and unbleached muslin. The width commonly em- 
ployed is 1^4 inches, and the length varies from 3 to 5 
yards. Several bandages may be made at once by having 



BANDAGES. 



167 



the material the requisite length, nicking the end at 1% 
inch distances, and pulling the alternate strips in opposite 
directions. These strips are rolled by hand or machine 
into a firm, even, neat roll, freed of shreds, and covered 
with a protective paper to keep them clean. 

An excellent material for bandages is a loose-woven 
muslin known as "water dressing," which may be had 
bleached or unbleached. It is very elastic, free from 
shreds, and conforms smoothly and neatly to the dressing 
and the head. It is used exclusively by some surgeons in 
this country. All bandages should be sterilized by dry heat 
(300° F.) for one hour before they are used. 

APPLICATION OF ROLLER BANDAGES. 

The art of properly applying a roller bandage to the 
eye ; so that it will protect and support the wound or pro- 
duce even pressure, as the case may be ; so that it will stay 
on ; so that it will look neat ; requires no little practice. 
The nurse should practise the single and double roller and 
the figure of 8 bandages, for one and for both eyes, many, 
many times on a healthy subject before trying to apply 
them on a patient. 

To apply the single roller bandage to one eye — for ex- 
ample, the right — the nurse, standing in front of the pa- 
tient, holds the free end of the bandage on the middle of 
the forehead with the thumb of the left hand, while she 
makes a complete turn round the head, going from right to 
left (patient's) just above the ears, covering the free end as 
she brings the bandage across the forehead. The bandage is 
continued half round the head again, but a little lower than 
on the first turn, so that it comes under the occiput and 
under the right ear and up over the right eye to the center 



168 



EYE NURSING. 



of the forehead, where it may be fastened with a safety pin 
and the remainder cut off. This is a very convenient band- 
age, as the end that comes up over the eye may be unpinned, 
the dressing removed, the eye examined and redressed, and 
the end brought up and again pinned (if unsoiled) without 
disturbing the patient even to move his head from the pillow 



(see Fig. 14). Where the left eye is to be bandaged, the 
free end of the bandage is held with the thumb of the left 
hand, but the bandage is carried from left to the right (pa- 
tient's) round the head, half round again and under the 
occiput, under the left ear, and up over the left eye to the 
center of the forehead and fastened with a safety pin. 
Where both eyes are to be covered with a single roller, in- 
stead of cutting off the bandage when one eye is covered, 
after the safety pin is fastened at the center of the fore- 




Fig. 14. — Single Roller Bandage. 



BANDACES. 



169 



head, the bandage is reversed and carried downward in 
front of the other eye and under the corresponding ear, 
under the occiput, and forward above the opposite ear to 
the center of the forehead. A second complete circular 
turn is taken around the head and the bandage fastened in 
front with a second safety pin (see Fig. 15). 




Fig. 15. — Double Roller Bandage. 

To apply the figure of 8 bandage to one eye (right 
eye), the free end of the bandage is held on the center of 
the forehead with the left thumb and the bandage carried 
to the left (patient's), making one complete turn round the 
head just above the ears; the bandage is then continued 
round the head on a little lower level under the occiput and 
under the right ear up over the right eye to the forehead ; 
a second circular turn of the bandage is taken round the 
head directly over the first circular turn; then a second 



170 



EYE NURSING. 



diagonal turn is made, the bandage being a little higher 
(Y 2 inch) on the side of the head above the ear on the left 
side, slanting down under the occiput, coming forward 
under the right ear and up over the right eye, on a little 
lower level inch) than the first lap, to the forehead, A 
third circular turn may be taken and also a third diagonal, 
this time being % inch, higher on the left side of the head 




Fig. 16. — Figure of Eight Bandage for one Eye. 

than the previous turn, slanting down under the occiput 
under the right ear and % inch lower on the right eye than 
the former turn, to the forehead; then a fourth circular 
turn is taken to make the bandage entirely secure (see Fig. 
16). Safety pins are used to fasten the bandage: one at 
the center of the forehead, one above the left ear, and one 
below the right ear. Instead of safety pins, inch strips of 
adhesive plaster, 2 inches long, may be used for this pur- 



BANDAGES. 



171 



pose. Only slight tension on the bandage should be used 
when the diagonal turns are made, but enough tension 
should be made on the circular turns to hold the bandage 
well in position. If the left eye is to be bandaged the 
bandage should be carried from left to right (patient's), 
or in the reverse direction to what was followed in bandag- 
ing the right eye. 




Fig. 17. — Figure of Eight Bandage for Both Eyes. 

To apply a figure of 8 bandage to both eyes, a circular 
turn of the bandage above the ears as for a single eye is 
first made, then the first diagonal turn as for a single eye 
(say, the right), then a second complete circular turn is 
made ; then the roller should be carried down over the left 
eye, under the left ear, and up under the occiput, slanting 
upward above the right ear to the center of the forehead. 
A third circular turn is now made, then a second diagonal 



172 



EYE NURSING. 



over the right eye, a fourth circular, a second diagonal over 
the left eye, and so on, the circular turns alternating with 
the diagonal ones (see Fig. 17). Safety pins, or, prefer- 
ably, strips of adhesive plaster, are used to fasten the band- 
age, at the center of the forehead and at each side of the 
head. If well applied, a single pin at the center of the 
forehead suffices to hold it on. 




Fig. 18.— Moorfield's Bandage. 



SPECIAL BANDAGES. 

A number of special bandages for the eyes have been 
devised, the most useful of which are the "Moorfields," 
Stephenson's "dumb-bell," and von Alt's "strips." The 
Moorfields bandage (see Fig. 18) consists of a double fold 
of linen, rectangular in shape, 8 inches long by 3 inches 
wide, out of one edge of which a notch is cut so that the 
bandage will fit over the nose and eyes snugly. To each 
corner is sewed a tape ; the tapes on each end are brought 
together so as to form a loop, leaving one free end of tape, 
however. When the bandage is in position the loops of tape 



SPECIAL BANDAGES. 



173 



fit over the ears, while the free ends are carried beneath the 
occiput behind and brought forward and tied over the fore- 
head. 

The Stephenson 1 dumb-bell bandage, according to the 
author, "can be made in a few minutes from a piece of 
Saxony flannel or domette. As shown in the figure (Fig. 
19), its shape resembles a dumb-bell, the handle of which 
passes over the nose, while the expanded ends fit over the 




Fig. 19. — Stephenson's Dumb-bell Bandage. 



eyes. This covering piece is fitted with two tapes, an inch 
in width, which are passed above the ears and round the 
head, to be tied together on the forehead." 

Von Alt's strips are really not bandages, but are used 
for the same purpose as the narrow strips of zinc oxide 
plaster to hold the dressings from slipping or becoming dis- 
arranged on the eye, while a bandage is placed over them 
just as over the adhesive strips. They consist of narrow 
strips of cheese cloth, 1% inches in width by 5 or 6 inches 
in length, which are placed diagonally over the eyes, from 



l "Ophthalmic Nursing," second edition, page 111. 



174 



EYE NURSING. 



the right frontal eminence across the left eye to the left 
cheek, from the left frontal eminence across the right eye 
to the right cheek. The ends are fastened to the face by 
means of adhesive plaster or zinc oxide plaster. These 
"strips" possess no special advantage over the simple nar- 
row strips of zinc oxide plaster and are not so easily 
managed. 

In children and unruly patients, after the ordinary 
roller bandage is applied, a few turns of a moistened 
starched bandage applied over it, or a bandage soaked in a 
solution of silicate of potassium or soda (40 per cent.), 
known as "water glass," and wrung out, may be used. 
These harden when dry and effectually hold the dressings in 
position and also protect the eye. 

The tie-patch is made of an oval piece of brown paper, 
3 by 2 inches, covered on each side with black silk. To each 
end a tape is sewed. This patch is very convenient for hold- 
ing temporary dressings (an eyepad) on the eye after re- 
moval of cinders from the eye or after slight injuries. 

Masks and Shields. 

Numerous masks or shields have been devised to place 
over the eye and dressings after operations upon the eye, 
to give greater security, where the anterior chamber has 
been opened, as after extraction of cataract. The shield 
protects the eye from rubbing by the patient or accidental 
knocks, especially at night when the patient is half asleep 
and does not know just what he is about. 

Eing's mask (Fig. 20) is the best of all the masks or 
shields with which I have had any experience. It is made 
of papier mache, about 8 inches long by 4 inches wide, is- 
lined on the inside with white muslin and on the outside 



MASKS AND SHIELDS. 



17-") 



with black muslin. It is shaped to fit the average sized 
nose, and protuberances come forward in front of each eye 
so as to give space for dressings. At each corner tapes are 
sewn, longer on one end of the mask, so that they may be 
carried round the head one above and one below the ear and 
tied on one side of the head. If it is desirable for the pa- 
tient to see with one eye, a piece can be cut out of the mask 




Fig. 20. — Ring's Mask. 



directly in front of that eye. Where no pressure or sup- 
port is to be made on the eye, the eyepads may be held in 
position with the strips of zinc plaster, and this mask 
placed directly over these. It thus takes the place of a 
bandage, leaves the eyes cool, and gives security at the 
same time. This mask has many advantages : it is light, 
comfortable, cool, and cheap (costing but 25 cents), and is 
destroyed when soiled or the patient is well. 1 



l They may be had of E. B. Meyrowitz, of New York City. 



176 



EYE NURSING. 



McCoy's shield (Fig. 2i) is made of wire in two cir- 
cular frames, held together by a loop and shaped somewhat 
like a rat-trap, the bases being about 3 inches across. It 




Pig. 21.— McCoy's Shield. 



can be made aseptic by boiling. It is applied over the eye 
dressings and held in position by means of tapes. 

Stephenson's wire gauze shield is made in -three sizes ; 
it is pliable, and can be molded to fit the face and dressings. 
It takes the place of a bandage and is useful for protection 
in case of children or restless patients to prevent them from 



REDRESSINGS. 



177 



pulling off the dressings. It is held in position by means of 
tapes, which are attached to eyelets at the ends of the 
shield. It can be made aseptic by boiling. 

Andrews's aluminum shield is made of thin sheet alu- 
minum, is about 3 inches in diameter, concave in shape, and 
can be bent somewhat to fit the dressings. It is applied 




Fig. 22. — Andrews's Aluminum Shield. 

over the bandage and held in position by means of tapes, as 
shown in Fig. 22. By dipping in boiling water it is made 
aseptic. Emerson has devised a shield of a similar nature. 

Eedressings. 

In making a change of dressings great care as to asep- 
sis and gentleness in cleaning the eye must be exercised. 
The nurse is to have in readiness a bowl of warm boracic 
acid solution (saturated), or bichloride of mercury (1 to 
5000) or other solution, according to directions of the sur- 

12 



178 



EYE NURSING. 



geon. Into this bowl of-solution should be placed a num- 
ber of cotton balls (mops) to be used in sponging the eye. 
A separate bowl with dry cotton balls should be at hand. 
In addition to these the necessary dressings, eyepads, gauze, 
bandages, zinc plaster adhesive strips, shields, safety pins, 
etc., together with the usual remedies, cocaine, atropine, 
eserine, silver nitrate solutions, iodoform, etc., all on a 
tray or in a basket should be on a table convenient to the 
patient. Some surgeons (Gruening) have a special basket 
to hold all the necessary dressings and remedies in con- 
stant readiness, so that the nurse is ready at a moment's 
notice to accompany the surgeon on his rounds in the hos- 
pital, warm solutions of boracic acid or bichloride being the 
only things necessary to get ready after the surgeon arrives. 

To remove a dressing. A towel should first be placed 
under the chin of the patient, and if much solution is to be 
used in softening the dressings, as after a plastic operation, 
a rubber cloth over this. The mask or shield must first be 
taken off; then the bandage is cut on the side of the head 
with a dressing scissors, or it may be carefully unwound, 
taking care not to drag the dressing off with it. If adhesive 
strips are holding the dressing they are loosened above, then 
a stream of the warm solution is squeezed from a cotton 
sponge on to the dressings and between the upper edge of 
the dressing and the eyelid, holding the dressing in the 
meantime with a dressing forceps in the disengaged hand so 
as to remove it when loosened by the solution. If the inner 
layer of gauze sticks to the lids, this should be thoroughly 
soaked with the solution, the upper edge loosened, and a 
stream of water squeezed from a cotton sponge between it 
and the lid. When the dressings are off, the edges of the 
lids are to be sponged with a wet cotton ball to free them 
of dried secretions, the lower lid pulled gently down, and a 



SHADES AND PROTECTIVE GLASSES. 



179 



little of the solution squeezed into the eye, if any mucus or 
discharge is present. The greatest of care is to be exercised 
in putting any solutions or drops into the eye, after the 
first two or three dressings following the operation for 
extraction of cataract, or other operations where the an- 
terior chamber is opened, especially until the wound is 
healed. The patient should always be warned just before a 
solution or a drop is to be put into the eye; because if put 
in suddenly and without warning, the patient is liable to 
jump, or squeeze the lids and to do great harm to the eye. 
In fact, I have seen an eye lost after extraction of a senile 
cataract by a drop of atropine being dropped carelessly 
into the eye on the third day after the operation, without 
warning to the patient, who squeezed the eyelids violently, 
opened the wound, expelling some of the vitreous, resulting 
in violent inflammation and loss of the eye. Worse, in 
this instance, sympathetic inflammation was excited in the 
fellow-eye, and that, too, was lost! 

The unoperated eye should be cleansed also, when the 
dressings are off. The dressings are then reapplied, but, be- 
fore the bandage is put on, the hair should be brushed. All 
discarded dressings are burned at once. 

It is hardly necessary to say that all antiseptic and 
aseptic precautions must be observed on the part of nurses, 
attendants, and the surgeon in redressing the eye, especially 
so until the wound is healed. 

SHADES AND PROTECTIVE GLASSES. 

After all dressings have been removed from the eyes, 
following operations, and in inflammatory conditions of the 
cornea and deeper structures, it is desirable to protect the 
eyes from the light. This may be done by means of shades 
or protective glasses. 



180 



EYE NURSING. 



Drop Shade. — This may be single or double. The 
single drop shade is semicircular in shape, 3 inches long on 
the straight edge and from 1% to 2 inches wide at the 
center. It is made of brown or other stiff paper and cov- 
ered with black silk on both sides. Tapes are sewn to each 
corner with which to tie it over the eyes. The drop shades 
bought at stores and held on by elastics are not desirable, as 
they cause too much pressure on the head and brow. 

The double drop shade is shaped very much like the 
Moorfields bandage, shown in Fig. 18, and is of the same 
size. It is made of the same material as the single shade ; 
at each corner, on one edge only, tapes are sewn with which 
it is tied to the brow, the lower edge hanging free and shad- 
ing the eyes. It may have a notch on the lower border for 
the nose, but this is rarely necessary. 

A shade, shaped like the bill or beak of a cap, may be 
made from stiff pasteboard or cardboard, and holes cut in 
each end into which tapes can be tied with which the shade 
is fastened on the head. 

In the country an ordinary sun-bonnet is often used by 
ladies as a shade, and, by the way, makes an efficient one.- 

Shades when soiled, or when no longer needed for the 
one case, should be destroyed, as they may convey infection. 

Protective Glasses. — These are often worn for the 
same purposes as shades. They come in several shapes and 
colors. When the light is to be kept almost completely 
from the eye, dark goggles with wire gauze at the sides fit- 
ting close to the orbit are to be preferred. Ordinarily, 
however, "coquilles" made in the London smoke glass are 
the best, the amount of light admitted to the eyes being 
gauged to some extent by the more or less dark tinting of 
the glass. No. 1 tint is grayish in color, while No. 7, the 
darkest tint that is made, is almost black. Tints No. 3 and 



ARTIFICIAL EYES. 



181 



No. 5 are the ones most commonly worn. Some surgeons 
prefer blue-tinted glasses, while some others order green or 
yellow. In recent years, a tinted glass known as Crookes, 
in two shades "A" and "B," has been much used, both as a 
protective glass and the lighter shade "A" ground in cor- 
rective glasses. 

Protective or shaded glasses should be plain, that is, 
have no refractive power. Occasionally glasses for visual 
purposes are ground in tinted glass, the Crookes' glass being 
the one most used for the purpose — in two shades — "A" 
and "B." 

Old, soft linen is the best material for cleansing 
glasses. When greasy, as when wet with perspiration, 
glasses should be washed with soap and water, to which a 
little ammonia is added. They are then carefully dried 
with soft linen. A clean linen handkerchief answers the 
purpose fully. 

Artificial Eyes. 

Artificial eyes are usually made of glass, and are worn 
in the empty orbit after enucleation, or over the stump of 
the eye after evisceration, as after the Mules operation. 
After enucleation the reform eye of Snellen, which is a 
hollow shell, should be used, as it gives more fullness to the 
eye and has not the sunken appearance of the ordinary shell 
or artificial eye. After the Mules operation, and where 
there is a considerable stump of the eye remaining, the 
simple concave shell is preferable. Artificial eyes should 
be inserted about one week after an enucleation, and in 
three to six weeks after a Mules operation. 

Any discharge from the orbit is a contra-indication to 
its insertion. Too long delay in inserting an artificial eye 
after enucleation allows the orbital tissues' to contract and 



1QO EYE NURSING. 

difficulty may be experienced in getting an eye of sufficient 
size into it. For this reason, the sooner an artificial eye 
can be inserted with safety, the better. 

The surfaces of the artificial eye should be entirely 
smooth and have no rough edges. It is a good plan to wear 
the eye for a few hours at a time, for the first few days, and 
gradually increase the time until it can be worn all day. 
At night it should be taken out, washed, dried, and laid 
away out of the dust till morning. The orbit should be 
washed with salt water or boracic acid solution night and 
morning, and, should any discharge or irritation of the 
orbit supervene, a mild astringent should be used. If the 
discharge is persistent a few applications of a 2 per cent. 
' solution of silver nitrate should be applied to the orbit, and 
the eye left out for a few days. An artificial eye should be 
renewed yearly ; certainly not longer than two years should 
elapse without a change, as the surfaces become roughened 
and cause irritation of the conjunctiva. 

To Insert an Artificial Eye. — First, elevate the 
upper lid with the thumb or finger of one hand. Second, 
moisten the. eye; push the broader end of the eye under the 
upper lid, gradually turning the broader end toward the 
temple until the eye is in a horizontal position and is 
pushed as high under the upper lid as it will go with com- 
fort. Third, while still holding the eye in this position 
with the right hand let go of the upper lid and pull down 
the lower lid with the left hand; now push the lower border 
of the eye into the lower fold, or cul-de-sac, with the right 
hand. 

To Take an Artificial Eye Out. — First pull the 
lower lid down with the finger of the left hand. Second, 
place the end of a blunt probe (a clean hair-pin will do) 
under the lower edge of the eye and gently lift it from the 



ARTIFICIAL EYES. 



183 



lower fold of the conjunctiva, when the eye drops out. A 
towel or other soft material should be spread over the lap 
of the patient to catch the eye. 

Patients learn quickly how to insert and remove these 
artificial eyes. When removing them they usually lean over 
a bed, pull down the lower lid powerfully, squeeze the lids 
tightly, and the eye "drops" out, usually requiring no probe 
at all. 



CHAPTER XI. 



WHAT TO DO IN EMERGENCIES. 

Injuries to the Eyes from Caustics and Burns— Contusions 
and Penetrating Wounds— Infectious Materials in the Eyes— 
Atropine Poisoning — Cocaine and Holocaine Poisoning. 

In emergencies it goes without saying that when a 
physician can be hafl. he should be sent for at once. In the 
meantime the nurse should be doing something, and that 
something should be the right thing. So great is the 
urgency in some instances, as in burns from lime, the 
mineral acids, and carbolic acid, the eye should be looked 
after immediately, and the physician sent for later. Quick 
action may mean the saving of eyesight and the escape of 
marked deformity. 

Injuries to the Eyes from Caustics and Burns. 

Lime Burn. — Lime in the eye in its pure state or in 
the form of plaster or mortar is not an uncommon accident. 
It acts as a violent caustic and corrosive, and if not seen 
speedily and removed does irreparable injury to the sight 
and often causes adhesions between the lids and the eyeball 
(symblepharon). 

No water should be used to remove lime from the eye, 
as water slacks the lime and causes it to burn worse. A 
clean handkerchief or a little piece of gauze smeared with 
sweet oil, castor-oil, vaseline, lard, or butter should be 
used to wipe every particle of lime from the eye. The lids 
should be forcibly everted, to see if any of the lime is in 

am 



INJURIES. 



185 



the cul-de-sac or deep folds of the conjunctiva. A satu- 
rated solution of sugar may then he used to wash the eye 
thoroughly, as cane-sugar forms an insoluble compound 
when mixed with lime, and thus neutralizes the action of 
the latter. If sugar is not convenient molasses may be 
poured into the eye. Vinegar answers the same purpose, 
and is usually to be had. It neutralizes the action of the 
lime. Iced cloths should then be applied until a doctor can 
arrive, the eye being protected in the meantime with 
vaseline, sweet oil, or castor-oil. 

Ammonia. — In case of an ammonia burn of the eye, 
vinegar or lemon juice may be used to neutralize the action 
of the ammonia. Then cold compresses should be applied 
to the eye. 

Mineral Acids, as Nitric, Sulphuric, etc. — The 
first thing to do in acid burn of the eyes is to wash the eyes 
immediately with an alkaline wash of some kind. Such 
solutions can be made quickly by mixing borax, soda (bak- 
ing soda), or potassium bicarbonate with water. Milk may 
be used if these cannot be had, or even plain water, in lieu 
of nothing else, to dilute the acid as much as possible. The 
eye and lids should then be covered with vaseline, oils, or 
grease of some kind, and iced cloths applied until the sur- 
geon can be called. 

Carbolic Acid. — This drug is in such common use 
that, by mistake, by careless handling, or at times by crimi- 
nal intent, it gets into the eyes. Several such cases «have 
come under my care. In one of these cases carbolic acid 
was dropped into the eye by mistake for cocaine. If these 
cases are seen to at once no permanent injury results. The 
eye should be washed with a solution of alcohol (1 part 
water to 3 parts alcohol) ; whisky or brandy in the same 
strength solution may be used if alcohol is not convenient ; 



186 



EYE NURSING. 



and plain water should be used if none of these are on 
hand. Vaseline or oils are used to protect the eye, and 
iced cloths applied to keep down the swelling and edema. 

Burns. — The eyes and lids are often injured by steam, 
boiling water, fats, or by molten solder or lead, hot cinders, 
ashes from cigar or pipe, curling irons, etc. The first 
thing to do here is to remove any foreign substance from 
the eye, if still in it, and then to protect the eye and lids 
with vaseline or oils. Over this may be placed an im- 
provised antiseptic dressing, as a clean linen handkerchief 
wrung out in a weak solution of carbolic acid (1 per cent.) 
or boracic acid (saturated). Iced cloths can be applied 
over this antiseptic dressing. Where the burn is very ex- 
tensive and accompanied by great pain and shock, stimu- 
lants should be administered and also opiates. 

Injuries to the Eyes by Contusion or by 
Penetrating Wounds. 

In all cases of injury to the eyes or e} r elids from vio- 
lence, especially where there is an abrasion, contusion, or 
penetrating wound, the first requisite is to wash the eye and 
wound with a clean solution of some kind. Boiled water 
allowed to cool may be had on most occasions. A saturated 
solution of borax, or boracic acid, or a 1 per cent, solution 
of carbolic acid, or of 1 to 5000 bichloride of mercury solu- 
tion may be used if conveniently at hand. If the eyeball 
itself is injured, in addition to cleansing the eye, a drop 
of atropine sulphate (1 per cent.) should be instilled if it 
can be procured. A clean handkerchief wrung out in sterile 
water or any one of the above solutions may be used as a 
dressing and held on with a bandage made from strips of a 
sheet or of an apron, until proper surgical assistance can 
be had. 



ATROPINE POISONING. 



187 



Infectious Material in the Eyes, as Pus from Gon- 
orrheal Ophthalmia, or the Membrane from 
a Diphtheritic Throat. 

Occasionally a nurse, attendant, or surgeon may have 
pus squirted into his own eyes while cleansing the eyes of a 
patient suffering with gonorrheal ophthalmia. It also hap- 
pens at times to have part of the membrane from a diph- 
theritic throat coughed into the eye of the nurse or surgeon. 
In either instance the very first thing to do is to wash the 
eye thoroughly with a solution of bichloride of mercury 
(1 to 5000) . Then drop into the eye 2 or 3 drops of a 2 per 
cent, solution of silver nitrate. If a 25 or 50 per cent, 
solution of argyrol, or a 5 per cent, solution of protargol 
is ready, either may be used in place of the silver nitrate. 
The above treatment is somewhat painful, but efficient. 
Iced cloths may be applied for a half hour to relieve the 
irritation. 

Atropine Poisoning. 

In poisoning from atropine, scopolamine, and other 
drugs of this nature, the throat is very dry, there is much 
difficulty in swallowing, and there may be dizziness. The 
pupils are dilated and fixed; the conjunctiva red and swol- 
len ; the face flushed, and, at times, affected with a pseudo- 
erysipelas ; and the pulse rapid. Convulsions may come on ; 
and delirium, ending in coma and death, ensues in some 
cases. Cardiac stimulants should be given at once, as 
coffee, whisky, and strychnine; and demulcent drinks to 
moisten the mouth and throat are indicated. In very 
severe cases hypodermic injections of morphine as a physio- 
logical antidote, and caffeine and camphor, as heart stimu- 



188 



EYE NURSING. 



lants, are to be given. Where there is marked stupor the 
application of hot bottles to the extremities and artificial 
respiration should be resorted to. 

Cocaine and Holocaine Poisoning. 

The symptoms here are usually weakness; dizziness; 
very weak, rapid, and irregular pulse; and, at times, de- 
lirium. Place the patient in the prone position and loosen 
the clothes about the neck and waist. Stimulate with 
whisky and coffee by mouth, and give camphor or strych- 
nine hypodermically. 



PAET II.-EAK. 



CHAPTER I. 

ANATOMY AND PHYSIOLOGY OF THE EAR. 

Anatomy. 

In considering the subject of the anatomy and phys- 
iology of the ear it is necessary, for the purpose of this 
book, that this chapter should be extremely elementary and 
brief. The duties of the nurse may be performed without 
a knowledge of the anatomy or physiology of the ear, but 
her work is rendered more efficacious, her technique more 
perfect, and the interest of her work is enhanced by an 
understanding of these points. If there is any wish to 
know more about the subject than, is given here, the nurse 
should consult one of the standard works upon the ear, 
where this information may readily be obtained. 

The ear is divided into three main chambers, which 
are en suite, just as one room of an apartment follows im- 
mediately upon another in a majority of the New York 
apartments. The first, or external chamber, is the external 
auditory canal. This has a very pretentious portal in the 
form of the external ear or auricle, which projects from 
the side of the head and is known as the ear. The second 
chamber of the ear is known as the middle ear, and this 
chamber is furnished with a hanging like a curtain, called 
the drum, which separates it from the external ear. This 
middle ear is furnished with three bones called ossicles, and 
named, respectively, the hammer (malleus), the anvil 

(189) 



100 



EAR NURSING. 



(incus), and the stirrup (stapes) . The first of these bones, 
the hammer, is attached to the drum on the middle ear 
side ; the next, the anvil, is attached to the hammer, and is 
also fastened to the roof of the middle ear chamber; the 
stirrup is attached by its small end to the anvil, while the 
footplate of the stirrup rests upon a small window which 
leads into the third chamber, or the internal ear. This 
third chamber of the ear is composed of two parts — one 
known as the cochlea, from its resemblance to the coils of 
a snail shell ; and the other part as the semicircular canals. 
Both the cochlea and the semicircular canals possess a win- 
dow which looks into the middle ear and lies on its inter- 
nal surface, while the cochlea and the semicircular canals 
themselves are contained within that part of the temporal 
bone which is known as the petrous portion. 

The stirrup fits into the window which leads from the 
cochlea chamber, but is separated from it by a small mem- 
brane, which is sometimes known as the internal eardrum. 
This opening from the middle ear into the cochlea, to 
which the stirrup is attached, is known as the foramen 
ovale. The opening of the semicircular canals into the 
middle ear is also partitioned from this cavity by another 
membrane. None of the bones of the ear touch this mem- 
brane, as we have found to be the case in the membrane 
which spans over the foramen ovale. This opening from 
the semicircular canals into the middle ear is known as the 
foramen rotundum. 

Patients often refer to the fact that there are three 
drums in each ear. By this they mean that the first drum 
is the membrana tympani, which is the membrane stretch- 
ing between the middle and the external ear; that the 
second drum is the membrane which stretches across the 
foramen ovale, separating the cochlea from the middle ear 



ANATOMY OF THE EAR. 



191 



and receiving the footplate of the stirrup upon its middle 
ear surface; while the third drum is the membrane 
stretched over the foramen rotundum, and separates the 
contents of the semicircular canals from the chamber of the 
middle ear. It is true that these are three drums, but it is 
better to disregard the term "drum" as applied to the last 
two membranes and reserve it for the large membrane 
which separates the external canal from the middle ear — 
that is, the membrana tympani. 

The external ear consists of two parts — the canal and 
the auricle. The auricle is composed of cartilage contain- 
ing many convolutions, and is covered with skin containing 
a small quantity of fat. The auricle is set on the head in 
such a way that it catches sound waves and transfers them 
to the canal of the ear. It is arranged so that it receives 
sounds coming anteriorly and somewhat laterally better 
than sounds coming from behind. The canal of the ear is 
continuous with the auricle, is about 1% to 1% inches in 
length, and oval in shape. The direction of this canal is 
forward and inward, and it is slightly curved in the middle, 
so that in order to see the drum at the opposite end of the 
canal it is necessary to lift the auricle upward and back- 
ward. This obliterates the curve in the canal and allows 
inspection of the drum. The canal of the ear is partly bony 
and partly membranous and cartilaginous. The bony part 
is internal. The canal of the ear is covered with skin, 
which contains near the external auditory canal a number 
of prominent hairs serving as a protection against insects. 
It also contains a number of glands which secrete what is 
known as earwax, the purpose of which is undoubtedly to 
afford a sticky surface that will prevent the entrance of 
insects into the deeper parts of the ear or will serve to 
catch particles of dust or other foreign material that may 



192 



EAR NURSING. 



be introduced within the canal. When the auricle is pulled 
upward and backward, if the external canal is open, it is 
possible to observe the drum (membrana tympani). This 
stretches across the canal of the ear and separates the mid- 
dle from the external ear. It is attached at its edge to a 
small rim of bone which in child life is separate from the 
temporal bone, but very soon becomes ossified and attaches 
itself to the surrounding parts as a part of the temporal 
bone. The drum of the ear is composed of fibrous tissue 
membrane, and on the side of the external canal is covered 
with a thin, layer of epithelium derived from the external 
canal, while on the opposite, or internal, side it is covered 
with a layer of mucous membrane derived from the middle 
ear. The position of the drum within the ear is not per- 
pendicular, but it is inclined from above downward, slightly 
inward and forward, so that it occupies an oblique plane. 
About the center of the drum, in many cases, may be ob- 
served, shining through it as a long white process, the long 
arm of the hammer. 

Internal to the drum is the cavity of the middle ear. 
This cavity in an average skull is a rectangular chamber 
measuring about % inch in height, % inch in length, and 
y 2 inch in breadth. The roof of the middle ear is known 
as the attic and is separated from the brain by a thin and 
delicate plate of bone, scarcely more than % 4 inch in thick- 
ness. In the back wall of the middle ear, at its upper part, 
is a large opening known as the mastoid antrum. This is 
a communication which exists between the middle ear and 
the mastoid cells, which lie posterior to the middle ear and 
within the mastoid portion of the temporal bone. This is 
one of the important landmarks to the operating surgeon in 
mastoid operations. On the wall of the middle ear nearest 
the median line of the body — that is, its internal wall — 



ANATOMY OF THE EAR. 



193 



one observes a marked prominence, which is the wall of a 
foramen conducting the facial nerve. This nerve is dis- 
tributed to all the muscles of the face, and if it is injured 
in the mastoid operation a facial paralysis results. In front 
of this canal for the facial nerve is the oval window ; on 
the floor of the middle ear at its anterior end is a large 
opening. This is the ear orifice of the Eustachian tube, the 
other end of which opens into the naso-pharynx. Beneath 
the floor of the middle ear and separated from it by a thin 
shell of bone is the internal carotid artery. The middle ear 
is not an empty space. It is lined, as a room is papered, 
with a mucous membrane, continuous with the mucous 
membrane of the naso-pharynx through the Eustachian 
tube. It also contains the three bones of the ear, or ossicles, 
and certain ligaments and muscles which hold them in 
position. The ossicle called the hammer is, as we have 
already mentioned, attached by its long process to the drum 
of the ear, while its head rests upon that part of bone 
described as the attic. It is kept in position by the liga- 
ments and is capable of slight motion by the action of the 
tensor tympani muscles upon the head of the hammer. 

The anvil is the second bone of the ear and lies be- 
tween the hammer and the stapes. Its base is attached to 
the head of the hammer. To the long process of the anvil 
is attached the stapes. The footpiece of the stapes fits into 
the oval window, and is attached to a membrane stretched 
across this opening. 

The remainder of the ear is known as the internal ear. 
It lies within the petrous portion of the temporal bone, 
and is divided into two parts — the cochlea and the semi- 
circular canals. 

The cochlea is a spiral canal with two and a half turns. 
The canal is wider at the mouth than at the top. The wide 

13 



194 



EAR NURSINO. 



part of the cochlea is the foramen ovale, to which it will be 
remembered the stapes is attached. The cochlear space is 
filled with a liquid known as the perilymph, and on the 
sides of the canal are to be found the terminal filaments of 
the auditory nerve, distributed particularly at the outer sur- 
face of each canal, and known as the organ of Corti. The 
finer anatomy of this terminal auditory nerve scarcely con- 
cerns us in this superficial description, but it is sufficient to 
say that the nerve terminates in a number of sensitive cells 
which, are bathed in the perilymph. The semicircular 
canals are known as the posterior, vertical, and horizontal. 
They are arranged in such a way that the three canals make 
five openings into the main ampulla, the base of which is 
the foramen rotundum, previously described. The audi- 
tory nerve is also distributed within the semicircular canal, 
but here it fulfills a different function from that in the 
cochlea. The auditory nerve enters this region through the 
auditory foramen. It is found within the middle fossa of 
the brain, and within the brain is distributed to the part 
known as the hearing center. 

Physiology. 

The external ear collects the sound waves and conducts 
them to the tympanum. It is possible also that the external 
hearing organ intensifies the sound. The auricle is cone- 
shaped, and is directed forward and outward in such a way 
that it will receive any sound wave which reaches the indi- 
vidual. As soon as the sound waves are received upon the 
surface of the auricle they are deflected by the internal 
curve of the auricle toward the external canal of the ear, 
and as they approach the internal part they' are, so to 
speak, packed together or condensed. In this way it is 
probable that the auricle not only collects the sound waves, 



PHYSIOLOGY OF THE EAR. 



195 



but brings them into a smaller space, so that more waves 
may be conducted through the smaller external canal of 
the ear. It will be noticed that the entire auricle inclines 
toward the external canal, and as soon as the sound waves 
have been deflected and condensed they impinge upon the 
walls of the external canal and are conducted through it to 
the drum of the ear. As soon as the sound waves reach 
the drum of the ear, this elastic membrane is made to 
vibrate by the impact of the sound wave against it. The 
drum membrane is forced forward, slightly inward, and in 
the intervals between the waves it recovers its former posi- 
tion. Thus a very rapid vibration of the drum is excited, 
which sets the entire contents of the ear in action. The 
ossicles of the ear are then brought into play, being drawn 
to and fro with each movement of the drum. The motion 
thus imparted to the hammer is successively received by the 
incus and stapes, and finally reaches the foramen ovale. 
The membrane of the foramen ovale is now set in motion. 
Its motion corresponds in intensity and frequency to the 
vibrations of the membrana tympani. The cochlear side 
of the membrane stretched across the foramen ovale lies in 
contact with the perilymph, which now also vibrates with 
each movement of this membrane. Thus the fluid within 
the cochlea is set in motion, and the fluid waves excite the 
terminal cells of the organ of Corti. This, in turn, excites 
the irritability of the auditory nerve, and the sensations 
thus excited in the nerve are appreciated at the brain center 
of hearing. 

It will therefore be seen that the sound waves cease to 
exist as vibrations as soon as they have touched the drum. 
They, are there transformed into mechanical movement, 
which is made possible by the tiny joints by which the 
ossicles are attached one to another. The method of trans- 



196 



EAR NURSING. 



mission changes again at the foramen ovale, where the 
impulse, which at first consisted of sound waves, then be- 
came mechanical movement, now acts upon a fluid, the 
equilibrium of which is disturbed, forming waves. This 
force is again changed to mechanical movement by contact 
with the end-cells of the organ of Corti, and again the char- 
acter of the sensation changes as soon as the nerve is ex- 
cited, but the nature of this change has not yet been demon- 
strated. 

The balancing power of the body resides in the semi- 
circular canals. It has been found that if the semicircular 
canals are disturbed experimentally in animals, or if they 
are destroyed by diseases in man, the equilibrium is dis- 
turbed. An animal whose semicircular canals are destroyed 
will not attempt to assume its customary position of rest. 
For instance, an animal which ordinarily rests upon the 
abdomen will remain upon its back if the semicircular 
canals have been destroyed; a horse, whose normal position 
is on its four feet, will lie upon the side or the back, and 
remain in this position indefinitely, if the function of these 
canals is abolished. A fish whose semicircular canals and 
other organs of equilibrium have been destroyed will swim 
quietly all day in any position in which he is placed — on 
either side or on his back; and a man whose semicircular 
canals have been destroyed by disease, loses the power of 
remaining upright, and is unable to rise from a recumbent 
position without falling. 

The function of the Eustachian tube is to ventilate the 
middle ear and to permit of an equal pressure of air on both 
sides of the drum. If, at a certain moment when the at- 
mospheric pressure on each side of the drum is the same, 
the Eustachian tube should become closed to the admission 
of air by means of a swelling of the walls of the tube, the 



PHYSIOLOGY OF THE EAR. 



197 



temperature of the air in the middle ear will at once rise 
and the air will expand. This expansion of air will result 
either in pushing the drum outward toward the external 
canal and holding it in this abnormal position, or the rare- 
fied air will escape through the Eustachian tube, leaving a 
partial vacuum within the middle ear. The partial vacuum 
will result in a disturbance of the equal pressure on each 
side of the drum, with the result that the drum will sink in 
because the atmospheric pressure will be greater than the 
pressure within the middle ear. Unless this is relieved by 
a ventilation of the tube, so that the equal air-pressure is 
re-established, the drum will finally occupy an incorrect 
position, and the middle ear will become congested and in- 
flamed from the constant suction to which its blood-vessels 
are subjected by the partial vacuum within the ear. It will 
be seen that the establishment of an exchange of air from 
the pharynx to the middle ear is one of considerable impor- 
tance. This is the only function of the Eustachian tube. 
When the tube is chronically blocked so that the air is 
either retained in an expanded state or as a partial vacuum, 
the pathological changes characteristic of partial deafness 
are slowly established. 



CHAPTER II. 



GENERAL METHODS OF NURSING IN EAR CASES. 

The Ear Douche — Ear Drops — Painting the External Ear — 
Ice Coil — Poultices — Heat — Medicinal Applications — Leeches — 
Method of Politzerization. 

The Ear Douche. 

Irrigation of the external ear is useful to facilitate 
the removal of material within the external canal of the 
ear, or as a method of applying heat to the ear for any pur- 
pose whenever it is indicated. It isi further useful as a 
method of applying medicaments to the canal of the ear, 
and is used by the aurist for all three of these purposes. 

The douche should be administered either by means 
of a douche bag holding two quarts or by means of a large 
metal or glass syringe, known as the ear syringe. The 
douche bag previous to being used should be sterilized by 
dry heat, if possible, but when this is not practicable it 
serves every purpose if some sterile water, or some 1 to 
10,000 solution of bichloride of mercury is run through 
the douche bag after the outside of it has been thoroughly 
scrubbed. A word of caution must be sounded against the 
indiscriminate use of old douche bags which may lie around 
the house and which have been used for many other pur- 
poses for a long time. These douche bags contain at the 
end of the rubber tube all kinds of bacteria, which, if they 
do not come in contact with the ear itself, often contaminate 
the surgeon's hands, and from him are conveyed to the 
patient's ear. Therefore, if an old douche bag be used, it 
should not only be thoroughly cleaned, but should be sup- 

(198) 



EAR DOUCHE. 



199 



plied with a new tube. The hard-rubber tip at the end of 
the tube which is to be used in the ear should be soaked in 
1 to 80 carbolic acid solution, or in alcohol, or else should 
be boiled before it is used on the bag. After the douche has 
been given, the bag must be dried and wiped, and after the 
tube has been cleaned the whole douche bag should be 
wrapped in a clean towel and laid aside until its next using. 

Ordinarily, the bag is hung on a projecting nail or 
held by an assistant at a height of about six feet from the 
floor. If the patient is sitting in bed or in a chair this will 
give a fall of water of from three to four feet, which is 
sufficient pressure for the purposes of douching the ear. If 
too much pressure is iised the douche is apt to cause pain by 
impinging forcibly upon the c^rum or the inflamed tissue. 
When the syringe is substituted for the douche bag the solu- 
tions are mixed as for the douche, but are sucked into 
a syringe from which they are injected with not too much 
force, the end of the syringe resting within the external 
canal of the ear. The syringe should also be kept as clean 
as possible if it is to be used for douching the ear, and it 
is a good plan to immerse the syringe, or the tip of the 
douche, in 95 per cent, alcohol when these small pieces are 
not in use. 

The solution for use in the douche bag may be of plain 
water or, more often, may contain a certain quantity of 
sodium chloride (salt), which is added to the water in such 
strength as to make the resulting solution about the specific 
gravitv of the blood (oss to *xvi). This solution is abso- 
lutely non-irritating, and so can ordinarily be used for 
syringing the ear. The nurse, however, may be called upon 
to make solutions of other chemicals for use in the douche 
bag or the syringe. Some of those most frequently used 
are lysol, in a strength of % drachm to the quart; boracic 



200 



EAR NURSING. 



acid, q.s. to saturated solution ; alum, 1 per cent. ; glycerine, 
4 per cent. ; glycerine and soda ( 1 drachm of each to the 
quart); alcohol, 10 per cent.; peroxide of hydrogen, 10 
per cent. 

These medicaments are put in hot water, and when 
they are thoroughly dissolved the water is allowed to cool 
down to a temperature of-about 110 degrees. At this tem- 
perature it is poured into the douche bag or sucked into the 
syringe, and when used represents a temperature of about 
106 degrees, which is the proper temperature for irrigating 
the ear, unless in a few very susceptible patients it produces 
too much burning, when the temperature may be reduced. 
In other patients it is possible to use a higher temperature 
than 10G, for, while some patients bear heat poorly, others 
can stand a very high temperature. During the giving of 
the douche the temperature of the contents of the bag is 
apt to lower a few degrees — three or four; so that it is 
necessary to add some hot solution to that already in the 
bag, in order to keep the temperature about 10G degrees. 

The patient is prepared for the douche as follows: 
The neck is bared to the clavicle and a piece of rubber 
sheeting is placed around the shoulder on the side to be 
treated, and tucked within the collar band. A pus basin or 
other properly shaped receptacle is placed under the lobe of 
the ear and firmly pressed to the side of the cheek. If this 
is carefully done and the vessel retained in this position, 
not a drop of water will escape below the basin. The pa- 
tient himself generally holds the basin, and I have noticed 
that they have a fatal tendency to incline the basin either 
forward or backward, generally to a considerable degree, 
so that as the basin fills the water is apt to run over and 
soil the clothing of the patient. 

Everything being in readiness for the douche, the 



EAR DOUCHE. 



201 



nozzle is placed in the patient's ear and the flow of water 
turned on. At first the external ear only is irrigated, but 
after a moment, during which time the patient becomes 
tolerant to the temperature of the water, the nozzle is in- 
troduced within the opening of the external ear and the 
water flows through the canal, generally as far as the drum, 
or to the first obstructing point, when it returns and drops 
from the lobe of the ear into the basin. 

The force of the douche depends greatly upon the 
condition of the patient. When it is desired to remove 
impacted cerumen (wax in the ear) it is necessary to use 
considerable force, and in this case there is no danger of 
injuring the drum of the ear, because the impacted ceru- 
men acts as a pad between the drum and the flow of the 
water. As the cerumen becomes loosened and comes away 
from the ear, it is necessary to use less force than before. 
In cases where the canal of the ear is much swollen from 
inflammation, it is useless to use much force in irrigation, 
and an attempt should be made to fit thenozzle rather accu- 
rately, so that the water will enter the ear as far as possible. 
The quantity of water ordinarily used for a douche is from 

1 to 3 quarts; but, unless it is specified by the physician, 
the nurse is to understand that if an ear douche is ordered 

2 quarts at a temperature of 106° are expected to fulfill the 
requirements. 

The douche is generally ordered to be given two or 
three times each day, but it is sometimes used as often as 
every two or three hours. After the douche has been com- 
pleted the head of the patient should be lowered and shaken 
so that the water will run from the ear, and a bit of dried 
cotton should be placed in the external canal of the ear, 
unless something else is ordered to follow the douche. 

Unfavorable symptoms as the result of using the 



202 



EAR NURSING. 



douche are rarely observed. Sometimes patients do not 
stand high temperatures well, and it is necessary to lower 
the temperature of the douche to a point which is agreeable 
to the patient. In a few cases the effect of such a quantity 
of water produces maceration of the epithelium of the drum 
and a swelling of the canal, or symptoms of dermatitis are 
excited by the heat. The maceration of the epithelium 
may be partly prevented by using a douche of proper spe- 
cific gravity — that is, by the addition of salt or soda to the 
water, in the proportion of 1 drachm to the quart. If a 
dermatitis is excited, it is necessary to coat the lining of 
the ear with a thin layer of vaseline before using the douche. 
In a few other cases patients complain of great pain after 
douching the ear, and a still smaller percentage have attacks 
of dizziness. Under such circumstances it may be neces- 
sary to stop the douche. 

WHAT IS ACCOMPLISHED BY THE DOUCHE, 

Discharges containing infective material are removed 
from the ear, and an opportunity is given any pus which 
may be behind the drum to push its way outward. The 
beneficial effects of the heat are also obtained from the 
douche, providing the temperature is high enough. This 
acts in many cases to prevent the further involvement of the 
deeper structures of the ear, and it is unquestionably true 
that even a few cases of mastoid involvement will recover 
without operation if the douche is used often enough and 
at a proper temperature. 

Ear Drops. 

A favorite method of using medicaments within the 
ear is by means of a medicine dropper. Various drugs dis- 
solved in water, glycerine, or alcohol are used in this way. 



EAR DROPS. 



203 



Generally, ear drops should be used warm. The drops may 
either be warmed before being sucked into the dropper or 
after the dropper is filled it may be held for a few seconds 
over a gas flame, when the liquid contents will become warm 
enough for use. The temperature of the drops should al- 
ways be tested by letting one or two fall upon the hand 
before they are used within the ear. As soon as the drops 
have cooled to the proper temperature, which is about 106°, 
— or, for practical purposes, when they are as warm as can 
be conveniently borne upon the skin of the hand, — they 
should be instilled at once into the ear. 

The head should be bent upon the opposite shoulder so 
that the ear to be filled lies uppermost. The auricle (ex- 
ternal ear) should be pulled slightly backward and upward, 
while at the same time it is raised from the side of the 
head, for this opens and deepens the canal. The entire 
canal of the ear is now filled with the drops and a piece of 
cotton is inserted in the exit of the canal, to retain the 
drops within the ear. If necessary, the other side may now 
be treated by reversing the position of the head and the 
ear filled in the same way- 

Generally the ear drops are not used until after the 
douche has been given. In this case it is necessary to 
empty the ear of the water contents resulting from the 
douche. This is done by turning the douched ear down and 
shaking the head. Sometimes the ear drops are used before 
the douche, particularly when the medicament is intended 
to destroy pus or to loosen the discharge. Peroxide of 
hydrogen is almost always used before the douche is given. 

Drugs that the nurse will be called upon to use as ear 
drops are, ordinarily, lysol, in the strength of % 0 of 1 per 
cent.; boracic acid, dissolved in either alcohol or water; 
a saturated solution of boracic acid dissolved in alcohol or 



204 



EAR NURSING. 



water or both ; cocaine and resorcin are favorite remedies to 
use in acute inflammations of the ear without suppuration, 
the vehicle for the solution being water. Cocaine is ordi- 
narily used in a 4 per cent, solution, and resorcin in a 5 
per cent, solution. Gtycerine — either in the form of plain, 
chemically pure glycerine or as boroglyceride — is frequently 
used in inflammation of the external canal, and sometimes 
in a watery solution is used for ear drops. A solution of : — 

Sodium bicarbonate 20 grains; 

Glycerine 2 drachms; 

Water 1 ounce; 

is a favorite solution in the Vienna Ear Clinic for the pur- 
pose of removing pus and debris from the ear and to pre- 
pare the ear for subsequent treatment. Alcohol, 95 per 
cent., is often used in cases of suppurative ear disease, and 
peroxide of hydrogen is a favorite treatment with many 
otologists. It may be used either in the full strength of 
the solution of the peroxide or it may be mixed with various 
portions of water, either 1 to 5 or 1 to 10, or 1 to 20. For 
very stubborn cases of discharge, solutions of nitrate of 
silver — 10 or 15 grains to the ounce — and solutions of 
chromic acid — 5 grains to the ounce — are used within the 
ear; but both these remedies stain the skin, and great care 
must be used to prevent them from dropping over the 
lobule of the ear on the skin of the neck. Occasionally 
medicaments dissolved in oil are used for the relief of pain 
or for ear discharges, but the best otologists look with dis- 
favor upon this form of treatment, although it continues 
to be a favorite treatment with the laity. With otologists, 
the use of oil within the ear is confined to cases requiring 
lubrication, particularly where there is eczema of the canal. 



EXTERNAL APPLICATIONS. 



205 



External Applications. 

The nurse is frequently ordered to make an application 
to the region behind the external ear, especially the mastoid 
process. The effect of this application is expected to be 
alterative or resolvent upon disease within the ear, or it 
may be used for the relief of symptoms, such as pain and 
swelling. Ordinarily, a strong solution of menthol and 
chloral, or a solution of iodine in alcohol (tincture of 
iodine), or an application of a solution of croton oil is the 
remedy to be used. Sometimes mustard plasters are 
ordered. Their application is a simple matter, and consists 
in rubbing the medicament over the region posterior to the 
ear for an area of two or three inches. A piece of absorbent 
cotton soaked in the medicament to be applied forms a 
ready means of making the application. 

The ice coil is an application that is frequently or- 
dered. Sometimes, instead of the ice coil, bladders or bags 
of rubber are filled with pieces of cracked ice and laid over 
the region of the ear. The present rule for the use of the 
ice coil is that it should never be used for more than twenty- 
four hours. If in that time it does not succeed in con- 
trolling the conditions for which it was ordered, no further 
benefit can be received from it. The application of the 
ice-bags or ice bladder is a simple matter. Care should be 
taken that the pieces of ice are not too large or sharp, 
so that if necessary the patient may lie upon the icebag, 
since in this position the drainage is better than if the pa- 
tient lies on the well side and the ice is placed upon the 
head. When the ice coil is used, it should be one of block 
tin, either round or else shaped to fit the ear. A long rub- 
ber tube is attached to each end of the coil — one tube to 
conduct the cold water from the tank and the other to carry 



206 



EAR NURSING. 



it from the coil into a receptacle placed upon the floor. 
The tank containing- the supply of water should be placed 
three feet above the bed of the patient and should be filled 
with rock salt, water and ice. The end of the tube is placed 
within the tank and the flow of water is started by drawing 
the water with the mouth or a syringe through the tube. 
From time to time the outlet tube should be raised to see 
that the flow of water continues. With care the ice coil 
may be made to work continuously. 

POULTICES. 

A favorite treatment with some otologists is the appli- 
cation of poultices of one sort or another, for the purpose 
of giving to the ear a certain quantity of heat and moisture. 
There seems to be considerable doubt as to how poultices 
act as therapeutic agents, but it has been definitely proved 
through ages of experience that the poultice is one of the 
most valuable remedies that we have in the treatment of 
inflammatory conditions. It is claimed by some that poul- 
tices act to resolve and scatter inflammation, but most 
physicians believe that poultices act to limit the areas of in- 
flammation, to increase the exudation of leucocytes, and in 
this way to increase the quantity of material which is drawn 
to a suppurating point for the purpose of destroying the 
bacteria causing inflammation. Besides this indirect power 
of destroying the bacteria through leucocytes by attracting 
them to the seat of inflammation, the heat of the poultice is 
useful for the relief of pain and is grateful to the patient 
from the support which it gives. 

A well-made poultice should be soft and hot, and 
should contain enough water so that it is very flexible. It 
should not be made so soft that the liquid contents could 
escape through the covering into the surrounding regions. 



EXTERNAL APPLICATIONS. 



207 



The poultice should be renewed as soon as its temperature 
lowers. Ordinarily ever}' hour or every two hours is often 
enough to apply a new poultice, but under some circum- 
stances the poultice may be left as long as four hours, par- 
ticularly if it is covered with rubber tissue and a bandage. 

A poultice may be made of a properly shaped piece of 
flannel which has been dipped in hot water, and over which 
a hot-water bag may be applied. This, is a convenient and 
ready form of poultice. 

Ordinarily, poultices are made up of a mass of water 
with starchy and oily material, such as flaxseed, slippery 
elm, or hops. Enough hot water should be used to make a 
soft and slippery mass. The water should be hot enough so 
that when the poultice is spread it will be necessary for the 
temperature to drop a few degrees before'the skin will toler- 
ate the heat. When the mass has been prepared, it should 
be spread between two layers of cheese cloth or thin linen — 
the edge of the cloth folding over the edge of the poultice 
so as to cover a part of its back and prevent the mass from 
oozing out between the layers. Sometimes poultices are put 
into bags made of similar material. The poultice should be 
covered with rubber tissue and retained in place by a prop- 
erly adjusted bandage. It is a good practice to lay a hot- 
water bag upon the poultice, for this keeps it warm for a 
long time. 

Great care should be taken that the poultice does not 
burn the skin. If they are applied too often or too hot, the 
skin becomes macerated and blisters, and in this condition 
it is very sensitive. In such cases the poultice can be dis- 
continued, a vaseline dressing applied, and time enough 
should elapse for the sensitiveness of the skin to lessen. 

A very satisfactory ear poultice may be made from a 
piece of absorbent cotton heated in plain water. This is 



208 



EAR NURSING. 



applied to the mastoid and auricular region, and over this 
a piece of rubber tissue is placed, and the whole mass con- 
fined beneath a thick layer of absorbent cotton and a gauze 
bandage. A very clean poultice which may be kept for a 
long time at a constant temperature may be made by put- 
ting a thick piece of cotton wet with hot water next to the 
skin, over this is placed a bit of rubber tissue and over the 
whole an electric heated pad (electric poultice). The heat 
from such a combination is steady and continuous. The 
renewals are necessary only when the cotton pad becomes 
dry. Instead of plain water the pad of cotton may be 
soaked in alcohol, menthol and alcohol, turpentine and 
water, alum solution or lead and opium lotion. 

Sometimes the external canal of the ear requires poul- 
ticing, and in such cases a very small cylindrical bag may 
be constructed, containing flaxseed, which may be placed 
within the canal; or' a convenient canal poultice may be 
made from the center of a roasted onion. An onion freshly 
roasted contains a great deal of moisture, which reaches a 
high degree of heat. If this is freshly split open a cone- 
shaped center is obtained which slips into the external canal 
quite readily. Such a poultice is certainly a very sterile 
one, since it is impossible for germs to reside within the 
layers of the onion. 

When poultices are ordered for ears which are dis- 
charging, they must be inclosed with sufficient care so that 
when the patient lies upon the poultice it will not press out 
upon the bed. This is very important, since a discharging 
ear drains better if the patient lies upon the side which is 
discharging, and a poultice subject to continual pressure 
from the head is very liable to break through its delicate 
covering of gauze and distribute itself over the patient's 
neck, or decorate his bedlinen. 



EXTERNAL APPLICATIONS. 



209 



If the skin shows any particular susceptibility to the 
application of the poultices — that is, if it becomes reddened, 
and more especially if it becomes tender to the slightest 
touch of the fingers, it should be protected from the direct 
application of the poultice by means of a rather generous 
layer of vaseline or ointment of the oxide of zinc. Instead 
of poultices, sometimes a substitute is employed in the 
shape of hot-water medicinal applications. These are 
medicaments dissolved in hot water and applied by means 
of a flannel which takes up a considerable quantity of the 
medicine with the hot water. These are applied after the 
excess of water has been wrung out, in the same manner as 
a hot flannel poultice is applied next to the skin. This is- 
covered with rubber tissue and kept in place by a properly 
applied bandage. Commonly such hot medicinal applica- 
tions are composed of weak solutions of turpentine, solu- 
tions of menthol, a solution of alum, the ordinary lead and 
opium mixture, or an ichthyol solution. 

LEECHES. 

The application of a leech to the mastoid region, or 
sometimes to the region over the parotid gland in front of 
the ear, is advised by many otologists and practised quite 
frequently. Care should be taken to choose leeches which 
have not been fed for some time. The leeches should be 
taken from the water in which they are swiinming and 
emptied into a dry box, and from thence received in the end 
of a leech tube. 

This leech tube is constructed of glass and can be ob- 
tained at almost any drugstore. The large end of the tube 
receives the head of the leech — that is, the end of the leech 
which rises in the air and marks the direction of advance- 
ment. The small end of the tube must be closed with the 

14 



210 



EAR NURSING. 



finger, but between the finger and the tube a small piece of 
paper should be placed, to prevent the leech from fastening 
to the finger of the nurse. The leech will not turn in the 
tube, so that the bare finger may be placed at the other end. 

The tube is transferred to the region to which it is> de- 
sired that the leech shall adhere, the bit of paper on the end 
of the tube removed, and the end of the tube applied di- 
rectly to the skin. If the leech is to be an active therapeutic 
agent he will, after a moment, fasten his head to the skin, 
insert his lancet, and begin to pump blood. During this 
period the tube should be retained in place, but after it has 
been found that the leech has fastened, the tube may be very 
carefully withdrawn, so as not to disturb the attachment of 
the leech. The posterior end of the leech will not remain 
attached to the tube, and when the tube is completely with- 
drawn it will gently fasten itself to the skin. Occasionally 
a leech will not fasten upon the skin, and this is generally 
due to the fact that the surface of the skin contains some 
salt. If a leech is reluctant to fasten, the part should be 
washed with plain water. Sometimes if they are reluctant 
to fasten after the skin has been washed, they may be coaxed 
to work by a weak solution of sugar and water placed on 
the skin. If after repeated trials the leech will not adhere, 
it should be thrown aside as worthless and a new one 
substituted. 

It must not be forgotten that whenever these animals 
are to be used the external canal of the ear must be plugged 
with cotton, for leeches which refuse to fasten sometimes 
wander quickly over the region of the head and have been 
known to make their way within the auditory canal, in 
which region they have been known to fasten, producing 
much fear, pain, and dread on the part of the patient. 

Three leeches are ordinarily applied, but as many as 



POLITZERIZATION. 



211 



six may be used. Generally two are placed in front of the 
ear over the parotid region, and four behind over the mas- 
toid. As the leeches fill with blood, their sucking move- 
ment grows less active and afterward very slow. At this 
moment they are ready to release themselves and as they do 
so they roll quickly over the neck and upon the shoulder or 
bed of the patient, They should be at once returned to a 
dry vessel, from which they should then be transferred to 
water, when after a period of fasting they will again be 
ready for work. 

The leech bite should be allowed to bleed. It should be 
treated with an antiseptic powder and dressing,- the same as 
any slight wound. 

Erysipelas sometimes arises in the site of the bite after 
leeching, and in such cases it is supposed that the erysipelas 
germs have been transferred to the patient from the sur- 
face of the leech. Against this there is no preventive, but 
fortunately the accident occurs very rarely. 

Preparation for Politzerization. 

This method is one of introducing air under pressure 
from the nose into the middle ear. It may be performed 
with a rubber bag and soft rubber tube with an olive pointed 
end, which fits into the nose ; or the bag may fit directly 
into the Eustachian catheter which has been introduced 
through the nose into the Eustachian tube. 

The nurse should prepare for this special treatment a 
Politzer bag, a Eustachian catheter, a few applicators 
wound with cotton (to remove the discharge from the ear), 
and an ear speculum. If the nurse is ordered to give this 
treatment herself, it will generally be suggested to her how 
it should be carried out; but it may be well, in case such 
instructions are omitted, to say that the nurse should never 



212 



EAR NURSING. 



use the Politzer bag with the Eustachian catheter, but only 
the bag to which is attached a soft rubber tube having a 
large olive pointed nosepiece. The nosepiece is introduced 
into the nose upon the side requiring inflation, and the 
patient's mouth is closed, while at the same time the oppo- 
site side of the nose, as well as the side containing the end 
of the Politzer bag, is kept tightly closed by finger pres- 
sure. At the moment when the patient fully puffs the 
cheeks, the bag should be quickly and firmly pressed, and 
the air will be blown into the middle ear. The operation 
of puffing presses the soft palate against the posterior 
pharyngeal wall and prevents the escape of air into the 
pharynx ; but in some cases the palate does not rise against 
the wall and shut the nose off from the throat. It is then 
necessary to have the patient hold a small quantity of water 
within the mouth, and at the bidding of the nurse the water 
should be swallowed ; at the moment when the larynx rises 
to its highest point during the act of swallowing, the water 
will have reached the pharynx and the soft palate will 
automatically lift against the posterior pharyngeal wall in 
this way shutting the nose off from the throat; when this 
moment has arrived, the bag should be firmly and tightly 
squeezed, and its air contents forced through the tube into 
the middle ear. 



CHAPTER III. 



PREPARATION FOR OPERATION. 

Sterilization for Operation — Sterilization of Nurse — Sterili- 
zation of Surgeon — General Directions for the Operation — Ar- 
rangement of the Aurist's Table — Arrangement of Instruments — 
Preparation of a Living Room for Operation. 

Sterilization for Operation in Ear Cases. 

When it is necessary to prepare the region of the ear 
for operation, unless a special method is indicated by the 
attending surgeon, the nurse should proceed as follows : 
The hair in the immediate vicinity of the ear should be 
clipped with a pair of scissors for a space of two inches 
behind and above the ear. After the hair has been clipped 
the scalp in this region should be shaved. Under some cir- 
cumstances it may not be necessary to cut away any of the 
hair ; and if it is decided that no hair need be removed the 
nurse should scrub the scalp and hair the day preceding the 
operation with tincture of green soap, which after being well 
rubbed into the scalp by friction of the fingers should be 
removed with plain hot water. The hair should then be 
dried and a second application of the tincture of green soap 
applied to the region of the hair and for two inches above 
and behind the ear. This should be left on the night pre- 
ceding the operation and in the morning of the day of oper- 
ation the area should be scrubbed again with green soap and 
water, during which time especial attention should be de- 
voted to the folds of the ear. An applicator wet with soap 
and water may be applied within the canal of the ear, and 
this region partially cleansed. A piece of cotton should 

(213) 



214 



EAR NURSING. 



then be placed within the canal and the ear thoroughly 
dried. It should then be scrubbed with bichloride solution, 
1 to 1000, and after drying again sulphuric ether should be 
poured on the cleansed part. It is now ready for operation. 

If the operation is not to be performed at once, a pad 
of wet bichloride solution, 1 to 5000, should be placed over 
the area and secured in position with a gauze bandage. 
When the patient is ready for the table, the bandage and 
pad may be removed, and an ordinary rubber bathing cap, 
such as ladies use, should be adjusted over the head, so that 
the hair may be kept from the wound and protected from 
soiling with blood. Tincture of iodine 3% per cent, solu- 
tion, painted over the parts to be operated upon and the 
adjacent regions, even upon the hairy parts, is a most effi- 
cient way to sterilize the skin. After two minutes it should 
be removed from the skin by washing the parts in alcohol 
applied on sterile' cotton. The field is now ready for 
operation. 

The patient should now be put upon the table, when 
the region may be sterilized again if it is thought advisable, 
by scrubbing with bichloride and the use of ether afterward, 
as has been previously described. If, however, the steriliza- 
tion has been carefully done, the case will not need another 
sterilization. 

The patient should lie upon the side which is not to 
be operated upon, and all but the region of operation should 
be covered with sterile towels secured in position with sterile 
safety pins. Of course, before the patient is placed upon 
the* table the general preparation is supposed to have been 
carried out — that is, no solid meals should be given for 
twelve hours before the operation, and for eight hours pre- 
ceding the operation nothing but a cup of plain broth should 
be given. The stomach should be absolutely empty for four 



PREPARATION FOR OPERATION. 



215 



hours preceding the operation, and the patient should not be 
allowed to have even a sip of water during this period. If 
the bowels have not been freely moved by the purgative 
which should have been administered twelve hours before 
the operation, they may be moved immediately before going 
to the operating table by means of an enema. 

To Arrange a Table for the Treatment of 
Ear Diseases. 

It is frequently necessary for the nurse to improvise a 
place for the otologist to treat a case of ear disease at the 
home of the patient, and it is a great convenience and 
economy of time if she understands how a table should be 
arranged for the treatment of ear disease. 

The first requisite is a fairly steady table, which should 
be covered with a clean tablecloth or with towels. Two 
chairs should be placed on one side of the table, in such a 
way that the right side of the patient and the left side of 
the physician will touch the table. Upon the table opposite 
the seat in which the patient is to sit, a light, either Argand 
or electric, should be placed, so that the height of the flame 
will be on a level with the ear of the patient. It is always 
better that the light should reach the headmirror of the 
physician on his left side, because then the right hand does 
not come within the line of the light. Upon the table 
should be placed two or three shallow dishes or deep soup 
plates, or a finger bowl. These should not be put on the 
table until they have been cleaned with boiling water and 
wiped dry. The douche bag should be filled with the proper 
irrigating solution when it is necessary to give a douche and 
should be ready for use. The nozzle of the douche bag 
should lie in an antiseptic solution upon the table. 



216 



EAR NURSING. 



It is necessary to have a certain quantity of absorbent 
cotton, a few sterile gauze pads, a tube of iodoform gauze, 
and a few bandages, ear specula and mirrors, as well as 
a few applicators on which cotton may be wrapped. Other 
instruments which may be brought by the surgeon may be 
arranged upon that part of the table nearest his chair. A 
few medicines which may have been forgotten by the aurist 
are always appreciated if present. The more useful of these 
are a 6 per cent, solution of cocaine, a solution of peroxide 
of hydrogen, a tube of sterile vaseline, and a quantity of 
powdered boracic acid. 

One of the dishes should hold a solution of lysol, V2 
drachm to the pint, for the reception of the instruments as 
they are used. 

Arrangement of an Instrument Table at the 
Time of Operation. 

When operations are to be performed in the hospital, 
the arrangement of the table to hold the instruments is a 
mere matter of routine, and the instruments are placed 
upon the table ordinarily by one of the physicians who is 
familiar with their position ; but in an operation in a pri- 
vate house it may be a part of the nurse's duty — besides 
arranging the room properly for the operation — to lay the 
instruments out on a table in a way that will meet the ap- 
probation and convenience of the operating surgeon. 

The instruments to be used in the operation should be 
taken from the receptacle in which they are brought to the 
house, and if they have not already been sterilized they 
should be divided into classes ; knives and needles, and other 
cutting instruments except scissors, should be placed in 
alcohol, 95 per cent., after they are wiped on a damp, ster- 



PREPARATION FOR OPERATION. 



217 



ile towel. Here they should remain until the other instru- 
ments have been sterilized and removed to the table. Then 
they may be taken from the alcohol and placed upon the 
table. The sharp instruments should be placed upon the 
table at the upper right hand. The remainder of the in- 
struments are transferred from the sterilizer, where they 
should have been boiled for fifteen minutes to half an hour, 
and placed in cold, sterile water. In this way they cool 
quickly and are more readily handled. They are then car- 
ried in this cold water to the operating room and arranged 
in somewhat like the following manner : The chisels should 
be laid upon the table near the knives. The handles of all 
the knives and chisels should point toward the operating 
surgeon, as in this position they are more easily grasped and 
there is less danger of wounding the fingers. The mallets 
should be placed next to the chisels. All bone-cutting in- 
struments and retractors should be placed below the knives, 
their handles pointing toward the operator. Needles, 
sutures, and ligatures should be placed in dry trays at the 
left upper corner of the table. Curettes should be arranged 
at the lower left hand corner of the table. The dressings 
to be used in the case should not be placed upon the instru- 
ment table, but should occupy a smaller adjoining table. 

Preparation or a Living Room for Operation. 

It is often necessary for a nurse to transform an ordi- 
nary living room of a private house into an operating room, 
and this frequently has to be done on very short notice. It 
is, however, not a difficult matter to arrange such a room 
in a fairly satisfactory way. 

The first requisite is good light, and, if the operation is 
to I >e prolonged after a time past 4 o'clock in the afternoon, 
the ordinary daylight, especially in winter, should not be 



218 



EAB NURSING. 



depended upon. In fact, some arrangement for artificial 
illumination should always be made — preferably by means 
of an electric bulb; but, if this is not forthcoming, then 
an ordinary Argand oil lamp is the best form of illumina- 
tion. Daylight, of^ course, is the best of all, but is not of 
great service if it is necessary for the aurist to work within 
the external auditory canal. In such a case, some artificial 
illumination is always needed. 

As soon as the nurse receives orders to prepare a room 
for operation, she should proceed in the following way : 
Two-thirds of the entire floor should be covered with sheets, 
including, first, that part of the floor where the operating 
table is to stand. These sheets should come fresh from the 
linen closet, and should not be unfolded until they have 
reached the operating room. They may be pinned or tacked 
over the carpet. 

For ear operations it is not necessary or advisable to do 
all the preliminary work for the preparation of a living 
room which is carried out in laparotomy cases. It is not 
necessary that the walls should be scrubbed or the carpet 
removed. After the sheets have been spread in position, an 
ordinary kitchen table should be carried to the room. This 
table should receive a thorough scrubbing with soap and 
water, or one of the sand soaps commonly found in kitchens, 
after which it may be dried. It should then be washed with 
a solution of bichloride of mercury, 1 to 1000, after which 
it may be carried to the operating room and placed in posi- 
tion where a side light can be secured. 

The nurse should now secure from the linen closet a 
number of clean sheets, 12 or 15 towels, and a pillow slip; 
and from the drugstore a pound of absorbent cotton and a 
quantity of absorbent gauze, which should be cut into strips 
and folded into pads. These pads should be in two sizes — 



PREPARATION FOR OPERATION. 



219 



3 by 4 inches, and 5 by 6 inches. A few pieces of narrow 
gauze packing should also be prepared. All the material 
from the linen room and drugstore should be wrapped in a 
clean sheet, when it may be sterilized in one of two ways : 
either by dry heat in the kitchen oven or by steam in an 
ordinary kitchen boiler. 

If it is to be sterilized in the oven, it should be wrapped 
in two or three layers of old cloth, to prevent burning, and 
placed in the oven for half an hour. It will then be thor- 
oughly sterilized, and the coverings will be more or less 
scorched. After the eoverings are removed, the dressings 
will be found sterile and unscorched. 

If the dressings are to be sterilized in a boiler, the 
latter should be placed upon the stove with hot water cov- 
ering its bottom to the depth of an inch. The packages of 
dressings are now laid within a sheet and this sheet is 
placed within the boiler in such a way that it is suspended 
above the water, the edges of the sheet lying over the rim of 
the boiler. The cover of the boiler is then adjusted so as to 
hold the sheet securely in place and the edges of the sheet 
folded over the top of the boiler cover and tied firmly. This 
holds the dressings suspended from the boiler top well over 
the water, and they are sterilized by the steam without 
becoming too wet. After thirty or sixty minutes of boiling, 
the steam will have penetrated every part of the packages 
and the dressings will be thoroughly sterile. They may now 
be taken from the boiler and carried to the place which is to 
serve as an operating room. 

The basins to be used in the room should be washed in 
soap and water and scalded with boiling water, both inside 
and out, and should then be allowed to become dry without 
wiping. 

In the improvised operating room the instruments 



220 



EAR NURSING. 



should be arranged opposite the side of the table where the 
surgeon will stand. This corresponds to the side opposite 
to the ear which is to be operated upon, the surgeon always 
standing on the side of the operated ear. The instrument 
table should be covered with a towel. Another table should 
be arranged with two bowls, one containing a solution of 
lysol, 1 drachm to the quart; and the other, a solution of 
bichloride of mercury, 1 to 5000. 

To the right of the head of the table a seat should be 
placed for the anesthetizer, and somewhere near this seat 
a very small table should be placed to hold his apparatus. 

The dressings should be placed on one side, and the 
packages of gauze and cotton which are to be used during 
the operation should be opened and placed on a table by the 
side of the surgeon. 

An adjoining room should contain material for the 
sterilization of the hands — a clean scrubbing brush, a quan- 
tity of tincture of green soap, plenty of hot water, and a 
nailbrush. The method of sterilization of the surgeon's 
and nurse's hands has been described at length in that part 
of this book which deals with "Preparation of the Nurse and 
Surgeon in Nose and Throat Operations," (page 267) 
The general duties of the nurse during an operation, as well 
as her surgical conduct, are also described in the same 
portion of the book. To these pages the nurse is referred 
for information on these points. 



CHAPTER IV. 



TREATMENT OF PATIENT AFTER OPERATION. 

Recovery from the Anesthetic — Powders — Dressing External 
Ear — Dressing! After Paracentesis — Dressing After Mastoid Oper- 
ation — Dressing After Furunculosis — Dressing After Ossiculec- 
tomy — Dressing After Leeches. 

Recovery from the Anesthetic. 

During the recovery from ether the patient should be 
left undisturbed unless continuous vomiting supervenes, 
and then disturbed as little as possible. If continuous 
vomiting threatens to cause bleeding or displace sutures, 
then as soon as semiconsciousness returns and the patient is 
able to swallow, a quantity of hot water may be adminis- 
tered; this hot water should be followed by a quantity of 
lukewarm water or by the introduction of a finger into the 
pharynx of the patient, so as to induce gagging and vomit- 
ing. The result of this is to eliminate very rapidly from 
the stomach a large quantity of ether which has been swal- 
lowed during the operation. If the patient refuses to vomit 
a stomach tube may be used and the stomach washed in the 
usual way. Many physicians do not use this method, but 
allow the patient to rest quietly until they have entirely re- 
covered from the anesthetic. After entire consciousness has 
returned the patient may be given small quantities of plain 
hot broth or hot water, and after four or five hours a larger 
quantity may be administered. Sleep should be encouraged 
and the room kept quiet and dark. 

(221) 



222 



EAR NURSING. 



The Powder Blower. 

The use of the powder blower, but more especially its 
care, is a duty which pertains to the nurse. As the powder 
blower is used quite often and ordinarily left exposed, it is 
necessary to speak of its care, since it may be an object of 
infection in an otherwise perfectly sterile technique. The 
powder blower before it is filled should be washed with alco- 
hol, and all of the parts used to project the powder should 
be soaked in 95 per cent, alcohol. From this it should be 
removed by sterile hands and allowed to dry in a warmed, 
sterile pan. When the alcohol is completely evaporated and 
the bottle and blower parts are dry, the antiseptic and 
sterile powder to be used may be introduced. 

It is now ready for use, but when unused should be 
kept carefully enveloped by a sterile towel, and after each 
use the end which has been near the ear should be immersed 
in alcohol and afterward allowed to dry. It is not neces- 
sary to sterilize the powder or the receptacle of the blower 
each time that it is used, but great care must be exercised 
with the tip. 

Dressing After Ear Operations, 
dressings after operations on the external ear. 

For plastic work upon the external ear the dressings 
will, under all circumstances, be left entirely to the physi- 
cian, who will make all the dressings until the case has 
progressed far enough not to need anything but ordinary 
surgical nursing. For the dressing of plastic operations it 
is necessary for the nurse to have ready solutions such as 
will be designated by the attending surgeon, or, if they have 
not been specially mentioned, a normal saline solution, 1 
drachm of salt to a quart of water; a solution of lysol, 1 



DRESSINGS. 



223 



drachm to a quart ; and a solution of bichloride of mercury, 
1 to 5000, are ordinarily used. There should also be a sup- 
ply of sterile cotton, some pads of gauze, and several band- 
ages 2 1 /) inches wide. For most plastic work rubber plaster 
is used, and a quantity of this should always be on hand. 
The rubber zinc oxide plaster is . the best. Rubber adhesive 
plaster may be sterilized by passing the cut strip through 
an alcohol flame — plain cloth side next to the flame and 
the adhesive side uppermost, or the strip may be cut the 
desired width and length, laid on a glass plate, put in a 
box, and exposed for one hour to formaldehyde gas. The 
strip after sterilization may be rolled with sterile hands 
upon glass rods. 

DRESSING AFTER INCISION OP THE CANAL OF THE EAR, 

In these instances (paracentesis operations) a douche 
is required, which should be prepared and administered as 
has been indicated on page 198. After the irrigation of the 
ear the canal is dried with bits of sterile cotton, and a 
dressing applied within the canal. Some surgeons use as 
a dressing for the canal a bit of sterile cotton about 1 inch 
long and of sufficient caliber to fill the canal. Some use 
this plain, others cover the surface of the plug with a 10 
per cent, solution of boroglyceride in glycerine ; and others 
with a solution of ichthyol and glycerine, 1 drachm to the 
ounce. A few otologists do not use cotton at all, but depend 
upon gauze packing within the external ear. For this pur- 
pose plain gauze, boracic acid gauze, or iodoform gauze may 
be used. After a paracentesis operation (cutting of the ear- 
drum) it is not necessary to apply any external dressing 
unless it is especially ordered. Then the entire ear may be 
enveloped with absorbent cotton held in place with a gauze 
bandage. 



224 



EAR NURSING. 



DRESSING AFTER MASTOID CASES. 

The greatest care is necessary in mastoid dressings to 
keep everything sterile, so that no contamination of the 
wound may occur after the operation. The nurse should 
have ready for the visiting surgeon a variety of dressings, 
a quantity of hot water and green soap, and a sterile hand- 
brush ; a quantity of plain, sterile water ; a basin of sterile 
salt solution, and a third basin with a quantity of bichloride 
of mercury, 1 to 5000. The instruments after sterilization 
may be used dry, or may be immersed in a solution of lysol, 
1 drachm to the quart. The dressings should be sterile, and 
usually consist of a quantity of absorbent cotton rolled into 
little sponge balls; some loose cotton; several folded pads 
of plain gauze; tubes of iodoform gauze or of any other 
medicated gauze which the surgeon may indicate ; a sterile 
powder blower containing iodoform or aristol; and a few 
gauze bandages, 2 1 /? or 3 inches wide. 

After the surgeon has cleansed his hands, the nurse 
with her bandage scissors should remove the gauze bandage 
and also remove the dressings or second layer of gauze pads 
which cover the wound. The rest of the dressing should be 
left to the surgeon. He will now remove the remainder of 
the gauze and expose the mastoid wound. 

A quantity of sterile solution should now be handed 
the surgeon with a few cotton sponges with which to wash 
off the skin of the mastoid before removing the gauze pack- 
ing. The solution should be either sterile, plain, or saline 
solution or bichloride, 1 to 5000. Before the gauze packing 
is removed from the wound, the canal of the ear should be 
irrigated with a normal saline solution and the entire ex- 
ternal ear cleansed. After the canal of the ear has been 
irrigated, it may be wiped dry by means of sterile cotton 



MASTOID DRESSINGS. 



225 



upon an applicator. The gauze packing in the wound 
should be removed with forceps, and the wound should be 
irrigated with one of the solutions which the surgeons may 
choose. The best solution for this purpose is probably a 
normal saline solution. At the moment of irrigating, the 
nurse should lift the cartilaginous part of the external ear 
upward and forward in such a way as to open the wound. 
After the washing is performed, the head of the patient is 
tilted in such a way that the fluid runs out of the mastoid 
region. The whole surface is then dried with sterile cotton 
wrapped upon applicators, or by inserting a few strips of 
sterile gauze, which readily absorbs the water in the wound. 

When the wound is dried, iodoform or aristol should 
be blown upon the granulations, only using enough to cover 
the granulations. Strips of iodoform gauze half an inch 
wide are now handed to the surgeon, who proceeds to pack 
the mastoid cavity, so that all the parts may be equally 
filled and the pressure upon the granulations equal in all 
parts. If the pressure is unequal, granulations will spring 
up in one part faster than in another and will leave a 
pocket which may afterward form a sinus. The first gauze 
should be introduced upward and forward into the mas- 
toid antrum and the gauze should be packed upon this 
first piece forward over the upper surface of the wound, 
until the region of the lateral sinus is reached. At this 
point care should be taken that the probe which is used 
to pack the gauze does not tear the sinus. At this 
stage of the dressing the patient's head is usually held by 
the nurse. After the antrum and sinus regions have been 
covered with gauze, the rest of the wound cavity is packed 
from above and inward, until the whole cavity is filled 
evenly with gauze. The incision through the skin should be 
firmly packed', so as to keep it open as long as possible. 

15 



226 



EAR NURSING. 



Some otologists now introduce a bit of cotton or gauze 
into the external ear, after the manner described under 
"paracentesis." If this is done, the gauze or cotton is in- 
troduced within the external canal as far as the drum, but 
is packed without any pressure. Folded gauze should now 
be laid upon the ear after the mastoid cavity has been 
packed, a strip of iodoform gauze may be laid upon the sur- 
face, and over this a layer of plain gauze to cover the entire 
ear. The first pad of gauze may be slit perpendicularly and 
the ear placed within the slit, so that the gauze will extend 
in front and behind the ear, the ear itself projecting through 
the cut in the gauze. The remainder of the gauze is simply 
laid upon this. If a thick dressing is desired, cotton is now 
applied, and the whole secured in place by a bandage 
properly applied. 

The mastoid bandage is a figure-of-eight bandage 
which covers the entire ear and mastoid region on the side 
of the operation. The bandage begins over the ear on the 
side opposite the operation. The first loop runs backward 
around the neck, over the operated side to the forehead, 
here the bandage is "turned" on itself and continued back- 
ward in the same manner, coming back over the operated 
side, the fold is carried over the top of the wound and low 
down over the forehead, the next time the bandage is car- 
ried near the lower part of the mastoid region and high up 
on the forehead. Thus the dressing is covered first by one 
turn lower down, then by one higher up, while over the fore- 
head the low turns over the operated side take a higher 
position while the high turns over the operated position 
take a low forehead turn. The bandage above the good ear 
is kept narrow. The bandage should be applied tightly. 

This procedure is repeated every day if the case is 
discharging, or every second to fifth day, if there is little 



MASTOID DRESSINGS. 



227 



or no pus. As the wound heals it must be made to heal from 
the deep part to the surface, otherwise pockets will form 
resulting in fistula? which will continue to discharge for a 
long time. It is possible that they may become infected and 
produce still further trouble, sometimes necessitating a sec- 
ond opening and curetting of the region which has been 
partly filled with infected granulation tissue. 

The duration of healing after a mastoid operation is 
from six to thirteen weeks. 

DRESSING AFTER FURITNCULOSIS. 

When a furuncle or boil has been incised it should be 
dressed after the manner described in this, book under the 
title "Dressing after Paracentesis." It is, however, the gen- 
eral rule for the packing to be saturated with a 10 per cent, 
solution of boroglyceride. This favors the exudation of leu- 
cocytes and serum, and tends to promote healing. 

DRESSING AFTER OSSICULECTOMY. 

In this operation two or three tiny bones within the 
middle ear have been removed. In such cases free drainage 
is quite necessary and irrigation is of great importance.. 
The tympanum and ossicles having been removed, the 
internal ear may be impinged upon by the solution used 
in irrigating, and considerable dizziness or vertigo result. 
As a rule, after ossiculectomy the ear should be irrigated 
every' third day, and dressed with a narrow strip of iodo- 
form gauze placed within the external canal, to prevent 
blocking of the canal and to facilitate capillary drainage. 
In cases where discharge has not been present before the 
ossiculectomy operation was done, it is not necessary to 
irrigate or to dress the wound so frequently. In such cases, 



228 



EAR NURSING. 



after the hemorrhage is stopped, iodoform gauze should be 
applied loosely within the canal of the ear, where it will 
furnish drainage for a couple of days. It should be re- 
moved, however, and the wound washed, upon the slightest 
increase of temperature. After washing, it should be re- 
packed without pressure, the gauze acting simply as a wick 
drain. 

DRESSING AFTER LEECHES. 

After leeches have been placed upon the ear, hemor- 
rhage should be favored by the application of hot water or 
by means of dressings wet in hot water for the first hour 
or two. After this, the wounds may be washed with a 1 
to 5000 solution of bichloride, and some sterile pads placed 
over the leech bites. The whole should be secured with 
bandages. This is particularly useful where it is desired to 
continue the bleeding from the wound, and the dressing 
may be renewed as often as it becomes saturated with blood. 
In other cases where leeches have been applied, the hemor- 
rhage ceases rapidly, and then the bites may be washed and 
dried and some flexible collodion afterward applied with 
a brush. 

In a few cases in my experience difficulty has occurred 
from continued hemorrhage. Pressure should then be made 
upon the leech bites by a properly adjusted gauze bandage. 
If this does not succeed in stopping the hemorrhage, the 
application of some styptic — such as chloride of iron, pow- 
dered alum, or solution of adrenalin chloride, 1 to 1000 — 
will succeed in producing a cessation of the bleeding, after 
which the case may be dressed as above described. 



CHAPTEE V. 



EAR NURSING IN SPECIAL DISEASES. 

Cerumen — Cutaneous Eruptions — Atresia of Canal — Foreign 
Bodies in the Ear — 'Paracentesis — Chronic Catarrh of the Middle 
Ear — Acute Middle Ear Inflammation, Catarrhal or Purulent — 
Chronic Purulent Inflammation of the Middle Ear — Treatment of 
Adenoids — Treatment of Deafness — Nurse's Duty in the Mastoid 
Operation — Ear Polyps. 

Impacted Cerumen, or Wax in the Ear. 

For this condition the nurse will be directed to intro- 
duce some drops within the external canal, thus softening 
the cerumen and facilitating its removal. Unless special 
treatment is ordered, the nurse is justified in using a full 
strength solution of peroxide of hydrogen, or what is known 
as a soda-glycerine solution, composed of equal parts of 
bicarbonate of soda, water, and glycerine. Either the 
peroxide or the soda and glycerine solution is introduced 
into the external ear with a medicine dropper, and when the 
ear is filled the solution is held within the ear by turning 
the head fo the opposite side. After a few moments the 
wax will soften considerably and may be removed with an 
ear douche. When the wax' has been removed, the nurse 
may look into the ear and will often be able to distinguish 
the drum glistening at the end of the canal. This will in- 
dicate that all of the cerumen has been removed. After 
drying the ear, a small piece of absorbent cotton should be 
introduced within the canal and left in place for twenty- 
four hours. If the inspection of the ear shows the presence 
of more wax, it is necessary to continue the douching until 

(229) 



230 



EAR NURSING. 



this is removed. In a very few cases the cerumen will not 
be removed by the douche, and it is necessary to use an ear 
spoon. This should always be done by the physician, and 
not by the nurse. 

Cutaneous Eruptions in the Eegion of the Ear. 

Certain cutaneous eruptions are common on the skin 
in the region of the ear. The treatment generally consists 
in the application of lotions or salve, for which general or- 
ders as to method of the application will always be issued by 
the attending surgeon. As a rule, however, it may be said 
that lotions should be applied by means of pledgets of cotton 
soaked in the solution and applied over the region affected. 
After using the lotion the skin may be left uncovered, when 
the lotion will dry upon it, or it may be covered with ab- 
sorbent cotton and a bandage. When salves are ordered for 
the skin of the ear, they should be rubbed for a few moments 
into the skin. Then a thin layer of salve should be applied 
over the affected area with a flexible steel knife, and cov- 
ered with a thin layer of gauze bandage. 

Atresia of the Auditory Canal. 

In cases of closure of the canal special orders will be 
given by the surgeon. These will depend upon the character 
of the closure. Should it not be a bony atresia, a firm plug 
of spongy wood or of compressed cotton will be introduced 
after the operation. If the closure of the canal is from 
follicular inflammation or periostitis., the surgeon will prob- 
ably order a twisted pledget of cotton soaked in some medic- 
ament placed within the ear. A medicament very com- 
monly used is a 5 per cent, solution of boroglyceride in 
glycerine. 



FOREIGN BODIES WITHIN THE EAR. 



281 



Foreign Bodies Within the Ear. 

In cases of this kind, particularly when living bodies 
such as fleas or flies are within the external ear, it may be 
necessary for the nurse to act as if in an emergency and do 
something to prevent the activity of the insect, for fre- 
quently serious constitutional symptoms arise from their 
presence. Almost all foreign bodies may be removed by 
means of a douche, which should be administered through 
a syringe, so that a stream of considerable force may be 
obtained. Before the douche is used it is well to fill the 
external canal with glycerine or olive-oil or sometimes alco- 
hol. These liquids, working past the foreign body, tend to 
float it out, so that it can be more easily expelled by the 
douche. After a few moments a syringe containing a nor- 
mal saline solution or plain hot water should be used, in- 
jecting the fluid into the canal with considerable force. 
This will often dislodge the foreign body, and it will drop 
into the pus basin held to catch the water. 

In the removal of foreign bodies it is well to remember 
three cardinal points : — 

First. — If the object is not at once washed away, the 
patient should be placed on a table lying on his side, so that 
the ear containing the foreign body is lowest. In this posi- 
tion it is often more easily ejected by the syringe than in 
the sitting posture. 

Second. — It must be remembered that certain vegetable 
materials — seeds, etc., — quickly absorb water and increase 
in size. This renders their removal from the small canal 
almost impossible without the use of an instrument If the 
history of the case shows that the foreign object is of vege- 
table matter, such as a pea or bean, no water should be 
used, but alcohol should be substituted as an irrigating fluid. 



282 



EAR NURSING. 



Third. — When living objects are within the external 
ear, they are frequently caught in the cerumen and die. 
Sometimes they remain alive and crawl against the drum. 
In this situation they produce distressing and painful symp- 
toms — great pain in the ear, severe headache, convulsions, 
and vomiting. Before these objects are treated in the usual 
way, it is necessary that they be killed. This may easily 
be done by filling the ear with olive-oil, which soon suffo- 
cates the insect. The subsequent treatment consists in irri- 
gation with water. If the object is very active, it is well to 
introduce a mixture of chloroform and olive-oil in the pro- 
portion of 5i-iv. This narcotizes and then kills the insect, 
after which it may be removed in the usual way. 

Larvae are sometimes deposited within the ear in un- 
conscious patients and are not noticed until they have 
hatched and appear as living objects in the canal. They 
may be killed instantly with a mixture of oil of turpentine 
and sweet oil, in the proportions of 1 to 10. They should 
then be expelled by hot-water irrigation. 

Paracentesis. 

This operation consists in making an incision through 
the drum of the ear through its posterior part for the pur- 
pose of allowing secretion to escape from the middle ear. 
The surgeon requires for this operation a knife, an ear 
speculum, several applicators wound with pledgets of cotton 
of small caliber, some peroxide of hydrogen, and a Politzer 
bag for inflation. 

The nurse's duties during this operation are to arrange 
the instruments and to hold the bead of the patient fixed 
and firm in case it is decided not to use an anesthetic other 
than cocaine. This operation is very painful unless done 



CHRONIC CATARRH OF MIDDLE EAR. 23o 

under general narcosis, but the pain may be lessened if 
cocaine is used freely for about fifteen minutes before the 
operation. The cocaine is applied by means of pledgets of 
cotton, or it is dropped directly into the ear. When the ear 
is cocainized, the nurse should hold the forehead of the 
patient in one hand and the occiput in the other in such a 
way that the head will be immovable. The patient will 
manifest considerable pain and will probably spring from 
the chair when the drum of the ear is perforated with the 
knife. The nurse should guard against this movement by 
firm pressure. No douching should be used after the ear- 
drum has been cut, for the result of this would be to intro- 
duce more liquid into the middle ear than is already present, 
and there would be a tendency to drive the pus toward the 
mastoid cells. Instead of douching, the Politzer bag should 
be used. The air entering the Eustachian tube and middle 
ear removes the secretion by blowing it through the incision. 

Chronic Catarrh of the Middle Ear. 

For the treatment of chronic catarrh of the middle 
ear, the nurse should ordinarily have ready for the physician 
a Politzer bag, any instruments which the surgeon may 
bring, particularly small syringes for the injection of med- 
icaments through the drum into the middle ear, and bougies 
for introduction through the Eustachian catheter into the 
middle ear for the treatment of the middle ear or the 
mucous membrane of the tube. 

The nurse may be ordered to prepare these bougies. If 
they are used plain, they should be sterilized by washing in 
plain water, after which they are dipped in a solution of 
lysol, wiped again on a piece of sterile gauze, and laid upon 
a dry cloth. Sometimes the surgeon will wish the bougies to 



234 



EAR NURSING. 



contain a certain quantity of silver. Silver was a favorite 
treatment in the Vienna clinic and is used rather exten- 
sively in other places. To make what is called a "silver 
bougie," they are placed in a 4 per cent, solution of nitrate 
of silver, in which they remain for a week. At the end of 
that time the material of ihe bougie has been thoroughly 
permeated with the silver solution. The bougies are then 
removed from the silver solution and dried in the open air. 
Such a bougie will then contain a quantity of nitrate of 
silver, which will exert its beneficial influence upon the 
middle ear when it is moistened by the discharge from that 
region. 

Stricture of the Eustachian Tube. 

This ordinarily complicates catarrh of the middle ear, 
and is treated with plain or with silvered bougies or by elec- 
trolysis. In the electrolytic treatment the catheter, which 
is introduced into the Eustachian tube, is carefully wrapped 
with rubber tissue for insulation. The gold bougie is run 
through the catheter to its end, from which it very slightly 
projects. The catheter is then engaged within the mouth 
of the Eustachian tube, into which the end of the bougie 
is then passed. When the gold bougie has been passed to 
the region of the stricture, the negative pole of the battery 
is attached to the end of the bougie and the positive pole is 
attached to a sponge placed upon the patient's wrist. The 
current is slowly turned on until the milliamperemeter 
measures 5 milliamperes. The duration of each treatment 
is generally for five minutes. 

Acute Inflammation of the Middle Ear. 
Earache. 

There are two classes of acute inflammations of the 
middle ear — one known as catarrhal, where the discharge 



ACUTE INFLAMMATION OF MIDDLE EAR. 235 



is of a mucoid nature; and another, purulent, in which the 
discharge consists of pus. The treatment of both classes is 
much the same, but differences of treatment may be indi- 
cated by the attending surgeon. The nurse's duty in these 
acute diseases of the ear consists in carrying out given 
directions to relieve pain, to drain the ear, and to produce a 
cessation of the discharge. For the relief of pain it may be 
necessary to introduce ear drops of one kind or another. 
Before the drops are introduced within the ear, the bottle 
in which they are held should be placed in a cup of hot 
water so that the drops may be properly warmed. They are 
then sucked into a medicine dropper and the affected ear 
is filled with the warmed liquid. Cold solutions are liable 
to increase the pain. 

When the ear has been filled with the warm drops a 
piece of cotton is inserted within the ear to prevent leakage. 
The drops are generally introduced as often as every hour, 
but may be introduced as often as every ten or fifteen min- 
utes if the pain is very severe. The ear bath or ear douche 
is also useful for the relief of pain. When the ear douche is 
used in this class of cases it should not be for over ten or 
fifteen minutes. The prolonged effect of hot water within 
the ear is to soften and macerate the drum, which, of course, 
is undesirable. The temperature of the water for the ear 
douche should be from 102° to 106° or 110° F. The differ- 
ence of 8 degrees between these extremes is the natural dif- 
ference which results from the varying tolerance of the 
patient for heat. The rule should be to use the water as 
hot as can be borne by the patient without increasing the 
pain. 

After the ear douche has been given, the ear drops 
are introduced as described above, and finally a piece of 
cotton fills the canal. The case may then be left without 



236 



EAR NURSING. 



further treatment until the next douche is ordered; or it 
may be necessary to use heat constantly in the form of 
moist hot gauze laid upon the ear or a rubber bag filled with 
hot water, upon which the affected ear should rest. If hot- 
water cloths are used, they may be wrung out in plain hot 
water, or if there is evidence of much redness in the ear 
and surrounding parts they should be wet with hot lead 
and opium solution. The severe pain in the ear is some- 
times not controlled by this method, even when strong anes- 
thetic ear drops have failed. 

The best ear drops to use in cases of severe pain are of 
a 10 per cent, solution of cocaine muriate with a 4 per cent, 
solution of resorcin. This solution, of course, should be 
used warm and may be introduced as often as every fifteen 
or thirty minutes. In a few cases it may be necessary to 
give the patient an injection of morphine ; % grain should 
be the first dose for an adult. 

Otologists are very apt to establish drainage through 
the Eustachian tube in both catarrhal and purulent inflam- 
mations of the middle ear, by forcing open the tube with 
an air current from a Politzer bag or by incision of the ear- 
drum. The treatment by politzerization and the relief of 
pain by means of ear drops, douche, etc., is a treatment 
which is used before the membrane ruptures. After the 
membrana tympani (drum of the ear) is ruptured, and the 
fluid of the middle ear allowed to escape, the treatment is 
often changed. The attempt on the part of the otologist is 
now to prevent infection of the ear and to cure the middle 
ear as quickly as possible. The treatment therefore will 
consist of a warm douche of boracic acid saturated solution 
— used as described under "Ear Douche," but in cases where 
the drum has been ruptured it is important to use but a 
weak stream of water, as too much force is apt to cause pain. 



ACUTE INFLAMMATION OF MIDDLE EAR. 



237 



After the ear douche has been used it is customary to in- 
troduce some ear drops within the canal. A favorite for- 
mula for this consists of cocaine, 2 per cent., in adrenaline 
solution. Another favorite formula is a solution of mor- 
phine sulphate, 3 to 5 per cent. 

As soon as the pain has ceased — and this generally oc- 
curs as soon as the drum of the ear is ruptured — an anes- 
thetic solution is no longer required, and an antiseptic solu- 
tion should be substituted. Such a solution is made of 
4 per cent, resorcin, or a 1 to 10,000 bichloride of mercury. 
When the drum is ruptured, the use of the Politzer bag 
should be discontinued. 

A few otologists still recommend what is known as the 
dry treatment for cases after the ear drum has ruptured. 
The dry treatment consists of carefully wiping out the dis- 
charge from the ear until the canal is thoroughly clean, after 
which the entire canal is filled with dry, sterile boracic acid. 
This is removed the next day or the day after, or as soon 
as it is soiled with the discharge, and by the same method 
of wiping out the canal. When the canal is again clean it 
is refilled with the dry boracic acid. In this method no irri- 
gation whatever is used and no drops are introduced within 
the ear. 

Peroxide of hydrogen is a remedy which the author 
believes should never be used in cases of catarrhal or puru- 
lent inflammation of the middle ear when the cases are 
acute; still it is a remedy which is often ordered by the 
otologist to be used warm within the ear as ear drops. 

Finally the attention of the nurse must be called to the 
fact that the presence of adenoid vegetation (enlargement of 
the third tonsil) is seldom absent in cases of children hav- 
ing discharge from the middle ear, and frequently the dis- 
charge will not cease until the adenoids have been removed. 



238 



EAR NURSING. 



It is hardly the nurse's duty to attend to the adenoids, but 
in case their possible presence has been overlooked and the 
nurse finds that the child is a mouth breather — particularly 
at night — it might be wise for the general good of the pa- 
tient to suggest their presence, as a possible cause for the 
continuation of the discharge — particularly if the attending 
physician seems to have forgotten this point. 

Chronic Purulent Inflammation of the 
Middle Ear. 

In cases of chronic purulent inflammation of the mid- 
dle ear the nurse may be ordered to douche the ear, and in 
a few cases may be intrusted with the use of the Politzer 
bag, for the purpose of driving the secretion from the mid- 
dle ear through the perforation of the drum into the 
external ear, so that it may be removed, by washing. The 
method of politzerization has already been described. 

There are a few special points which may be mentioned 
in discussing irrigation of the ear in these cases of chronic 
discharge. One of these is the danger of producing vertigo 
from the pressure of water upon the labyrinth of the ear. 
When there is a large perforation in the drum, if the douche 
is used with too much force, the water may be injected 
through the opening of the drum and make pressure upon 
the labyrinth. Immediately the patient will be seized with 
headache and vertigo, which may be slight or may be so 
severe that he will fall unconscious from the chair — or will 
only be prevented from falling by holding firmly with both 
hands on some object. This may be avoided by lessening 
the pressure of the syringe or by lowering the level of the 
douche bag. 

Attention should also be paid to the frequency of irri- 
gation, to the temperature and specific gravity of the water, 



CHRONIC PURULENT OTITIS. 



239 



to the force of the current, and to the medicaments which 
are to be used for irrigation. The temperature of the water 
should be from 102° to 10G° ; the force of the injection 
should be that fall which is produced by raising the douche 
bag about three feet above the patient's ear; the strength 
of the solution should be from % to 1 per cent., if it is a 
saline solution; but if a solution of boracic acid is used it 
should be saturated. Other medicaments are usually 
ordered to meet particular indications. They are ordinarily 
solutions of lysol, 1 per cent.; creosol, 12 per cent.; for- 
malin, Y 10 of 1 per cent. ; bichloride of mercury, 1 to 5000. 
In cases where the odor is bad, sometimes instead of the 
bichloride solution potassium permanganate solution, 1 to 
2000, is used for deodorization. If peroxide of hydrogen is 
used in these it should be used in the proportion of 1 

to 10. In a few cases, where the discharge is very abundant, 
as well as thin and watery, the best irrigation consists of a 
solution of oil of turpentine in the proportion of 15 drops 
to a quart of water. 

After the ear has been politzerized and then douched 
it must be thoroughly dried by means of pledgets of cotton 
introduced within the canal. When all the water has been 
dried from the ear it is ready for the physician, who will 
then apply any special treatment that is indicated. This 
is ordinarily either a powder or a caustic treatment, or the 
use of certain astringent remedies. If a powder is used 
after the cleansing it may be of plain boracic acid, iodoform, 
iodol, resorcin, or aristol. These may be used plain or 
mixed with certain* other powders which serve as diluents. 
Drops are employed sometimes instead of powder. These 
may be used after the manner described in the discussion 
of ear drops, and are peroxide of hydrogen ; a solution of 
mercury bichloride in alcohol, 1 to 5000 ; an ichthyol solu- 



240 



EAR NTRSTNG. 



tion; or plain alcohol. If the physician decides to employ 
the caustic treatment, which is the one ordinarily applied 
to reduce granulation tissue within the middle ear, he will 
probably use nitrate of silver, which he will apply as a small 
bead fused upon a probe or else in a cauterizing solution of 
60 grains to the ounce. In a few cases other cauterants are 
used — trichloracetic acid, lactic acid, and the galvano- 
cautery are the favorites. When an astringent remedy is 
ordered to be used after a douche, it will ordinarily be a 
solution of silver nitrate — 10 grains to the ounce; zinc 
chloride, 2 grains to the ounce ; copper sulphate, 10 grains 
to the ounce; alum, 20 grains to the ounce; or alumnol, 20 
grains to the ounce. 

Some otologists, in addition to these methods, treat 
the middle ear with a syringe having a fine silver cannula. 
The syringe is filled with the medicament desired, which is 
generally one of those mentioned above, and by means of 
a good illumination and an ear speculum the cannula is 
introduced through the perforation of the drum and the 
cavity of the middle ear is thoroughly medicated. 

Treatment of Adenoids. 

In most cases of chronic inflammation of the middle 
ear, especially in children, it may be taken for granted that 
the presence of adenoid tissue in the naso-pharynx is one 
of the elements in keeping up the discharge. The nurse's 
duty in adenoid cases, before, during, and after the opera- 
tion, has been discussed in that part of this book which 
deals with that subject. The fact of their possible existence 
should not be forgotten, and the child who has ear discharge 
should be carefully watched for the ordinary symptoms of 
adenoids, which are mouth breathing, snoring, and nasal 
discharge. 



NURSING OF DEAF CASES. 



241 



Treatment of Deafness After Ear Discharge 
has Ceased. 

The cases of chronic purulent inflammation of the 
middle ear result in more or less impairment of hearing. 
There is generally some retraction of the drum, and for 
the treatment of this resultant condition politzerization, 
massage of the drum of the ear, or the use of an artificial 
drum are the means ordinarily used to improve the hearing. 
Massage of the drum is a favorite method of treatment with 
many otologists, and is carried out with very simple or very 
complex apparatus. All of the instruments used to apply 
massage to the drum act by producing a vacuum and then a 
condensation of air in the external ear. By means of this 
the drum is drawn toward the instrument or pushed away 
from it, slowly or rapidly, as the air is exhausted or com- 
pressed. In this way the drum is moved from its position 
backward and forward, and small adhesions within the 
drum, or from the drum to the middle ear, are ruptured, 
and the elasticity of the drum improved. The circulation 
of the middle ear also seems to be improved by this alter- 
nating rarefaction and condensation of the air. 

The simplest method of accomplishing this purpose is 
by means of the Siegel otoscope, which is fitted closely to 
the borders of the canal of the external ear while compres- 
sion and suction is made upon the bulb, held in the hand. 
The effect upon the drum is observed through the glass 
window in the otoscope. 

The treatment by means of a pump or cylinder is 
applied upon the same principle, and is much more satis- 
factory and certain in its results. This pumping apparatus 
may be driven by a pedal and belt attachment or by means 
of an electric current. 

10 



242 



EAE NURSING. 



In another class of cases where the drum has sloughed 
away, or is absent from other causes, the use of massage is 
contra-indicated. In these cases, after the discharge has 
ceased, the patients hear better if an artificial drum is intro- 
duced. The best form of artificial drum consists of a small 
circle of flexible rubbber or silk carrying in the center a 
metal rod so that it may be easily removed. Sometimes 
these drums do not act as well as the introduction of a small 
piece of cotton rolled into the form of a ball and placed in 
the external ear at the old position of the drum. Care must 
always be taken to have the cotton sterile and to roll it into 
shape with sterile fingers. 

Nursing in Mastoid Cases. 

In the operative treatment of chronic purulent dis- 
charge of the middle ear the nurse may be called upon to 
assist in an operation for paracentesis ; or she may be called 
upon to treat the ear after the canal has been incised, ac- 
cording to the method previously described under "Furun- 
culosis"; or she may be called upon for aid in a mastoid 
operation. The preparation of the patient and of the room 
is described in Chapter III of this part. 

In any case of disease of the ear when involvement of 
the mastoid is suspected the nurse's duties are of the highest 
order of importance, and she must apply the treatment indi- 
cated conscientiously and regularly. She must carefully 
observe the patient's symptoms, particularly those which 
will be described hereafter as unfavorable symptoms. These 
must be carefully charted and upon their earliest appear- 
ance must be fully reported to the attending physician. As 
soon as mastoid disease is suspected, a coil for the applica- 
tion of either heat or cold may be ordered. This coil is 
used after the manner described in Chapter II of this part 



NURSING I N MASTOID CASES. 



243 



under discussion of the ice coil. If heat is ordered, the 
methods of employing it are discussed under "Hot Medic- 
inal Applications," in the same chapter. 

Leeches are very frequently ordered very early in mas- 
toid involvement. Their use has been discussed in Chapter 
II of this part. 

Some cases of mastoid involvement subside without 
developing a condition which requires operation, but a num- 
ber of cases will require opening of the mastoid cells. Op- 
erations in the mastoid region are either a partial operation, 
which involves opening of the cells and their curettage, or 
a radical operation which involves the entire removal of the 
cells as well as of the structures within the middle ear. The 
anatomical details of this operation need not concern the 
nurse, but her especial duties are practically the same in 
either case. 

When the mastoid cells are to be opened, her first duty 
is to see that the room is properly prepared, and that the 
proper dressings and sterile coverings are provided and 
placed in the operating room. (See Chapter III.) 

Her next duty is to see that none of the necessary in- 
struments have been forgotten, for in mastoid work time is 
an important element and the work cannot be properly car- 
ried out unless the requisite instruments are at hand. In 
many operations it ia possible to improvise instruments or 
to substitute one instrument for another, but this is not pos- 
sible in mastoid work. The nurse should therefore see that 
upon the instrument table are placed chisels — straight and 
gouged, a scalpel, mallet and periosteal elevator, retractors 
— sharp and blunt, artery clamps, dressings, forceps, and 
curettes. A special instrument known as the Stacke pro- 
tector is also convenient when the middle ear is to be 
entered. Besides these, there should be silk, needles, probes, 



244 



EAR NURSING. 



cotton sponges, and solutions, general directions for which 
have been given in Chapter III of this part. The instru- 
ments should be sterilized in boiling water for thirty min- 
utes. All sharp cutting instruments, such as knives and 
scissors, should be immersed in alcohol, wiped with gauze 
wet with alcohol or ether, and placed dry upon the table. 

The preparation of the patient has been described in 
Chapter III of this part. 

After the operation has been completed, irrigation, 
iodoform or plain gauze, gauze pads, and a bandage will be 
necessary. The first dressing is generally made by the op- 
erating surgeon, but the nurse may be requested to adjust 
the bandage. A proper bandage for mastoid cases should 
begin on the side opposite the operation, pass forward over 
the forehead and operated side, pass to the occiput, and then 
forward to the point of starting, in this way encircling the 
head. As few folds of the bandage should be used as will 
be necessary completely to cover the field of operation. 
(See also Dressing after Mastoid Cases, page 224.) 

THE NURSE'S DUTY AFTER THE MASTOID OPERATION. 

The temperature of the patient must be carefully 
watched, and if necessary it should be taken in the rectum. 
The nurse must watch other symptoms, particularly if their 
advent indicates a bad condition of the wound or the devel- 
opment of some complication. Profuse secretion after mas- 
toid operation is a bad symptom, indicating that the entire 
focus of disease has not been removed or that bacterial in- 
fection is going on unhindered by the operation. After 
mastoid operation the temperature should drop to normal 
or nearly normal, and should run along with a slight even- 
ing rise not above 99° F. for the first week after the opera- 



NURSING IN MASTOID CASKS. 



245 



tion. It should then reach the normal point and remain 
there. 

If the temperature rises suddenly, it indicates a pro- 
gression of the poisoning from the pus, or the development 
of a complication, which should be reported to the physician 
at once. Sometimes as soon as the temperature rises the 
patient will be seized with a chill. This usually means that 
meningitis is about to develop or that the lateral sinus 
has been infected. Headache and vomiting are other cere- 
bral symptoms which are apt to follow a chill, and indicate, 
as does the chill, that cerebral complications are developing 
and that the situation is extremely grave. In a few cases 
erysipelas will develop as a wound complication. This is 
shown by the presence of swelling in the immediate vicinity 
of the mastoid, with a cessation of all discharge, or the sub- 
stitution of a thin, watery, ichorous discharge, for the ordi- 
nary purulent discharge which follows the mastoid opera- 
tion. Infection of the wound by erysipelas is accompanied 
by a chill and rise of temperature. 

If none of these unfavorable symptoms which have 
been mentioned appear, the patient should be kept in bed 
and the bandage unchanged. At the end of the fifth day 
after the operation the wound should be dressed for the first 
time. 

In preparing for the first dressing, care must be taken 
that everything is sterile. The nurse must be as particular 
in preparing the room and the material as she was at the 
time of the operation. The first dressing is more important 
than the subsequent ones, but for each dressing sterile 
material must be prepared, and opportunity given to the 
surgeon to cleanse his hands. Irrigating fluids and re- 
ceptacles for solutions should be sterile, and care must be 
used not to carry infected material from the hair of the 



246 



EAR NURSING. 



patient into the wound. Ordinarily redressing is required 
every third or fourth day for a period of two to five weeks. 
At the end of five weeks the wound should have nearly 
healed, but it may require a longer time. For mastoid 
dressings a favorite plan of procedure is to irrigate the 
wound after wiping off the skin in the region of the mas- 
toid. The best solution to use for irrigation is a bichloride 
of mercury solution, 1 to 10,000, or, if the wound is in first 
class condition, sterile water or sterile saline solution alone 
is necessary. After drying out the wound, iodoform gauze is 
gently introduced — or aristol or plain, sterile gauze may be 
substituted for the iodoform gauze, if it is desired. The 
wound is then covered with pads of sterile gauze. The pad 
next the ear is generally slit, and through this slit the ear 
is introduced, so that the entire external ear is surrounded 
by the gauze, and the other layers of gauze are packed upon 
this one. Over the whole, a quantity of absorbent cotton 
and a bandage are adjusted. 

If the discharge from the wound is very profuse, so 
that the dressing is thoroughly wet through at the end of 
twenty-four hours, it is wise to change this dressing for a 
wet one. The best solutions with which to wet the gauze 
applied next to the ear are lysol solution, 2 per cent. ; 
peroxide of hydrogen, full strength ; or bichloride of mer- 
cury solution, Y 10 of 1 per cent. Mastoid cases are slow to 
recover. Professor Politzer, in his work on ear diseases, 
states that healing in mastoid cases requires from one and 
one-half to nine months for a complete cure, and that the 
average case requires from three to four months to get well. 
In cases where abscess develops within the cranium, or 
where meningitis is present as a complication of mastoid 
disease, the nurse's duties arc similar to those in an ordinary 
mastoid operation, except that the case partakes more of the 
character of a general surgical case. 



ACUTE HYPEREMIA OF LABYRINTH. 



247 



Some of the symptoms which indicate the beginning 
of meningitis are chill, high temperature, headache, vomit- 
ing, alteration in the mental condition, with the develop- 
ment either of a slight grade of stupor which gradually in- 
creases to unconsciousness or else the development of an 
irritable mental condition with convulsions. The head is 
then to be covered with an icecap, leeches are applied to 
the cranium at the base of the brain, and purgatives — par- 
ticularly croton-oil, 2 drops — or some other active purga- 
ti\ i — are ordered. Most of these cases prove fatal, but the 
small percentage which recover are helped only by surgical 
procedure. 

Ear Polyps. 

In cases where the external ear contains granulation 
tissue — which afterward dev|}ops into ear polyps — it is or- 
dinarily necessary to remove the polyp. This may be done 
by a method of snaring and curetting. The snare should 
be used if the polyp is small. After the polyp has been re- 
moved, the nurse should hand the operating surgeon some 
silver nitrate, which he will fuse upon a probe by holding 
the probe in the gas burner until it is heated and then dip- 
ping it into the powdered nitrate of silver, allowing the 
silver to melt upon the end of the probe. When this is cold 
it will form a small bead upon the end of the probe, with 
which the base of the polyp should be cauterized. 

Sometimes instead of nitrate of silver the surgeon may 
order a caustic known as monochloracetic acid; and in a 
few cases he may use the galvanocautery. 

The after-treatment for these cases consists in the use 
of alcohol. The effect of the alcohol is to heal the small 
areas of granulation tissue which may be left after the 
polyps have been removed. It should be introduced within 
the ear after the manner described under "Ear Drops." 



248 



EAR NURSING. 



-Cases of Acute Hyperemia of the Labyrinth. 

Cases of acute hyperemia of the labyrinth are very rare. 
They are accompanied by intense vertigo, and require abso- 
lute rest in bed with the head kept upon the mattress un- 
supported by pillows. The slightest movement of the head 
produces intense vertigo and vomiting. In such cases, the 
nurse will be instructed to use the ice coil or icecap, to 
administer a hot foot-bath, and sometimes to put leeches 
upon the mastoid. All of these, procedures have been 
described under their various heads, to which the nurse is 
referred for fuller information. Purgation is likewise a 
valuable remedy. The directions for giving this will be 
issued by the attending physician. 

In cases of Meniere's disease, where deafness, dizzi- 
ness, and vomiting are the prominent symptoms, the nurse's 
duties are similar to those described in the preceding 
paragraph. 



PART III -NOSE AND THROAT. 



CHAPTER I. 

ANATOMY AND PHYSIOLOGY OF THE NOSE, 
NASOPHARYNX, AND LARYNX. 

The Anatomy or the Nose. 

The organ of the sense of smell is divided into two 
nasal chambers, the external and internal nose, as well as 
into two sides, separated by the nasal septum. The external 
nose is that part which is so prominent upon the surface 
of the face. It occupies only about one-tenth of the 
entire- area of the nose. The internal nose extends from 
the margin of the cheeks, backward to the naso-pharynx. 
It is not a simple cavity, but has communicating with it 
several other chambers, distributed throughout the bones 
of the head, which are known as the accessory sinuses of 
the nose. 

The external nose contains a space known as the vesti- 
bule, or entrance to the nose, which is continuous with the 
space of the internal nose. 

The internal nose begins at the anterior end of the 
inferior turbinate body, and extends from the roof of the 
mouth below to the floor of the brain above and backward 
as far as the posterior end of the inferior turbinate body 
— the beginning of the naso-pharynx. The internal nose 
has on each side a roof, an inner wall, a floor, and an 
external wall. The floor of the nose is concave from the 

(249) 



250 



NOSE AND THROAT NURSING. 



front backward, as well as from side to side, the posterior 
end lying to. a lower level than the anterior. The roof of 
the nose is very narrow, scarcely wider than the end of an 
ordinary probe. It is perforated with many foramina for 
the distribution of vessels and for the olfactory nerve. The 
internal or septal wall, in a normal specimen, is perpen- 
dicular, and is composed in front of a cartilage which is 
known as the triangular cartilage, while the posterior two- 
thirds are bony. These parts are known, respectively, as 
the cartilaginous: and the bony septum. The external wall 
of the nose is not so simple in construction. At the floor, 
the external wall is farther away from the median line of 
the body than at the roof. This means that the space of the 
nose is greater at the floor than at the roof, due to the 
obliquity of the external nasal wall. The external nasal 
wall supports three bones, which are known as the turbinate 
bodies. The largest of these is the inferior turbinate body, 
and is attached to the external wall about 1 inch above the 
floor of the nose. It then curves inward and downward 
into the nasal space, and reaches within % inch of the 
floor of the nose. The middle turbinate body is attached 
to the wall 1 inch above the inferior turbinate body, but 
is shorter than the other, beginning on a line y 2 inch 
posterior to it. Both of these turbinate bodies end at the 
same perpendicular line behind. The superior turbinate 
body, so called, although it is not a turbinate body at all, 
occupies the posterior part of the external wall. Unlike 
the other two turbinates, it is not detachable without break- 
ing into other structures of the nose. It cannot therefore 
be termed a turbinate ; it is really the inner wall of the 
posterior ethmoidal cells. 

The presence of these three bodies on the external nasal 
wall produces a natural division of the nasal space into 



ANATOMY OF THE NOSE. 



251 



three cavities, which are termed the inferior meatus, the 
middle meatus, and the superior meatus. The inferior 
meatus of the nose is the space between the floor of the nose 
and the lower border of the inferior turbinate body. The 
wall of the inferior meatus contains the opening of the 
lacrymal duct. This is the only opening into the inferior 
meatus. 

The middle meatus of the nose begins at the lower 
border of the inferior turbinate and ends at the lower bor- 
der of the middle turbinate. It is bounded on the inside 
by the nasal septum by a line drawn from the septum to the 
lower bonier of the inferior turbinate, and by the upper 
surface of the inferior turbinate. Externally it is bounded 
by the external nasal wall, and comprises a deep recess be- 
tween the middle turbinate and the external nasal wall, into 
which so many of the accessory sinuses empty. It is 
bounded above by the external surface of the middle tur- 
binate, and by a line drawn from the lower border of the 
middle turbinate to the nasal septum. About the middle 
of the middle meatus one finds a deep sulcus known as the 
hiatus semilunaris. This sulcus extends from above down- 
ward and backward. A probe passed through the upper end 
of the hiatus at once finds its way into the frontal sinus, 
while one passed at the posterior end of the hiatus enters 
the antrum of Highmore. Along the upper wall of the 
hiatus will be seen several openings, — as few as two or as 
many as six. These are the openings of the anterior eth- 
moidal cells, all of which discharge their contents into this 
region. 

The superior meatus is bounded on the inside by the 
nasal septum; above by the roof of the nose; below by a 
line drawn from the lower border of the middle turbinate 
to the nasal septum and externally by the septal side of the 



252 



NOSE AND THROAT NURSING. 



middle turbinate and that part known as the superior tur- 
binate. This region contains the openings of the poste- 
rior ethmoidal cells, which open into the deep sulci, — gen- 
erally two and sometimes three, — known as the ethmoidal 
sulci. Besides these, the sphenoidal sinus opens into the 
superior meatus at its posterior and upper part, in a region 
known as the spheno-ethmoidal sulcus. 

The accessory sinuses of the nose are those cavities 
which communicate with the nose and increase the nasal 
area. They are (on each side) a frontal sinus, the antrum 
of Highmore, the ethmoidal sinus, — divided into anterior 
ethmoidal cells and posterior ethmoidal cells, — and the 
sphenoidal sinus. This makes a total number of eight 
sinuses, the surface area of which is much greater than the 
area of the main nasal cavity. 

It is not necessary for us to describe these sinuses in 
detail, but it is well to repeat certain facts about them which 
it will be of advantage to the nurse to know. The frontal 
sinus is located between the two layers of the frontal bone 
and lies directly above the eyebrow. Its size varies consid- 
erably and it is often absent. It communicates with the 
nose through a small opening on its floor, which is known 
as the naso-frontal duct. This opens into the middle 
meatus of the nose in the sulcus known as the hiatus semi- 
lunaris. The posterior wall of the frontal sinus supports 
the anterior lobe of the brain, and this important anatom- 
ical relation makes disease of the sinus or operation upon 
the sinus a very difficult problem, on account of the possi- 
bility of infecting or penetrating the brain. 

The antrum of Highmore is located under the eye in 
the body of the superior maxillary bone, and it is generally 
the largest of the accessory nasal cavities. It is pyramidal 
in shape, with its apex reaching out into the cheek (malar) 



ANATOMY OF THE NOSE. 



253 



bone. The base of the sinus is the external nasal wall, and 
the cavity of the sinus occupies a position in relation to 
the nose, so that it lies opposite both the inferior and mid- 
dle meatus. Its lower boundary is the alveolar process, 
into which the roots of the teeth are fixed; its roof is the 
floor of the orbit. This cavity communicates with the nose 
by means of its antral orifice, which opens into the posterior 
and lower end of the hiatus semilunaris. 

It will thus be seen that the openings of the frontal 
sinus and the antrum of Highmore are at opposite ends of 
the deep sulcus on the external nasal wall, in the middle 
meatus, which is known as the hiatus semilunaris. The 
important relation of the antrum is with the orbit, and care 
must be taken in the operations upon this cavity not to per- 
forate the roof and enter the orbit. It also has an impor- 
tant relation to the infra-orbital nerve which lies in a canal 
on the antral roof. 

The ethmoidal sinus is divided into two parts, known 
as the anterior ethmoidal cells and the posterior ethmoidal 
cells. The anterior ethmoidal cells open into the middle 
meatus of the nose, while the posterior ethmoidal cells all 
open into the superior meatus. The entire ethmoidal sinus 
extends from the posterior wall of the frontal sinus back- 
ward to the sphenoidal sinus. Its important relations are 
with the orbit, from which it is separated by a very thin 
layer of bone, and with the brain. The anterior lobe of the 
brain lies upon the roof of the ethmoid cells. 

The sphenoidal sinus, located within the body of the 
sphenoid bone, is a large accessory nasal cavity, cuboid al in 
shape, which communicates with the superior meatus 
through the spheno-ethmoidal sulcus. It has important 
relations on its upper and outer wall with the optic nerve ; 
the third, fifth, and sixth nerves ; the Gasserian ganglia, and 



254 



NOSE AND THROAT NURSING. 



a very important relation with the internal carotid artery 
and the cavernous sinus. 

Anatomy of the Naso-pharynx and Pharynx. . 

The naso-pharynx begins where the nose leaves off, at 
a line perpendicular to the posterior ends of the turbinate 
bodies, and extends in a curved line as a dome-shaped cavity 
backward and downward to the level of the hard palate. 
It contains normally on its lateral walls the openings of 
both Eustachian tubes and at its roof a certain quantity of 
adenoid tissue called the adenoid tonsil or the third tonsil 
or the pharyngeal tonsil. 

The oral pharynx, described in a simple way is the 
space behind the mouth and contains the soft palate and the 
uvula, which laterally divides into two bodies, known as 
the anterior and posterior pillars of the fauces. Between 
these two pillars the tonsil is included, while the uvula lies 
at its upper part, extending downward in the median line. 

The anterior part of the pharynx is open, communi- 
cating with the mouth. Its posterior part is a mucous mem- 
brane covering the scalenus muscles. Its lower part con- 
tains two openings : one into the esophagus, through which 
food enters into the stomach, and the other into the larynx, 
which conveys air to the lungs. 

Anatomy of the Larynx. 

The exterior or the frame of the larynx is composed 
of two large plates of cartilage joined together in front, 
known as the thyroid cartilage. These cartilages are united 
in front in the median line, but are separated widely he- 
hind, thus making an angular shield, which protects the 
interior structure of the larynx. The prominent part of 



ANATOMY OF THE LARYNX. 



255 



the thyroid cartilage may be felt in front of the neck, and is 
known as Adam's apple. The other cartilage which com- 
poses the frame of the larynx is known as the cricoid. This 
is located below the thyroid cartilage and is separated from 
it by a membrane known as the crico-thyroid membrane. 
The cricoid cartilages resemble a signet ring, with the face 
of the ring placed posteriorly. On the top of the wide part 
of the cricoid cartilage rest the two arytenoid cartilages 
that serve at their anterior part for the attachment of the 
vocal cords. The structures of the interior of the larynx 
are the epiglottis, the false and true cords, containing be- 
tween them the vestibule of the larynx and the sinus of 
Morgagni. 

The epiglottis is an ovoid plate of cartilage free above 
and attached below by ligaments to the tongue and to the 
thyroid cartilage on its posterior surface. It serves as a 
door to prevent food and foreign matter from entering the 
larynx. Its position is upright during phonation, but it is 
practically horizontal during the act of swallowing. 

The false vocal cords are two bundles of muscle fibers 
placed on each side of the larynx. They have nothing to 
do with phonation except as they change the position of 
the true cords by acting on the movable cartilages of the 
larynx. The true cords are located below the false cords, 
and are attached to the thyroid cartilages on their respective 
sides and immediately next to the median line. They are 
attached behind to a prominent process on the anterior sur- 
face of the arytenoid cartilages, and are, like the false cords, 
bundles of muscle fibers. They differ from the false cords 
in possessing a few strands of fibrous connective tissue 
stretching from the arytenoid process forward to the at- 
tachment of the cord, thus making a slight edge on the sur- 
face of the true cord. 



256 



NOSE AND THROAT NURSING. 



Between the false and true cords is a space known as 
the vestibule of the larynx, which is continuous with a 
small cavity lying between the false cords and the interior 
surface of the thyroid cartilage. This space generally ex- 
tends to the top of the thyroid cartilage, and is known as the 
sinus of Morgagni, or the sinus of the larynx. The mus- 
cular structures within the larynx are covered with mucous 
membrane. The term "chink of the glottis" is applied to 
the space between the edges of the true cords during quiet 
respiration, and the term subglottic is applied to the region 
beneath the true cord. 

Physiology of the Nose, Naso-pharynx, Pharynx, 
and Larynx. 

The nose serves as a filtering medium. By means of 
the ciliated epithelium it entangles the dust particles and 
transfers them backward into the naso-pharynx. In this 
way the dust particles are prevented from entering the 
accessory sinuses; the hairs at the entrance of the nostril 
serve the same purpose, and prevent the entrance of flying 
insects. The nose supplies a large quantity of moisture by 
which the humidity of the inspired air is increased. This 
is a very important function, for air is rarely breathed 
humid enough to keep the air-vesicles of the lung in a moist 
condition, thus favoring the introduction of oxygen into the 
blood and the elimination of carbonic acid from it. It is 
estimated that nearly a quart of water is secreted from the 
nose in the course of twenty-four hours, but the mechanism 
is so delicately constructed and the balance so perfectly 
adjusted that under normal conditions not one drop of this 
escapes from the vestibule of the nose, for it is, all used by 
the inspired air. 



PHYSIOLOGY OF NOSE AND THROAT. 



257 



The nose is also a warming medium for the inspired 
air, and it is estimated that the temperature of the exter- 
nal air is raised nearly to the body temperature in the short 
time taken for the inspired air to travel from the end of the 
nose to the pharynx. The correctness of this observation 
may be doubted, but it is safe to state that the air is raised 
many degrees in temperature in its passage from the nose 
to the lungs. The nose also serves as. a resonator for the 
voice, and modifies its character and tone. In this function 
the accessory sinuses are said to play a very important 
part. 

The nose is also the organ of olfaction — the seat of the 
sense of smell. The nerves for this special sense are dis- 
tributed through a small region on the mucous membrane 
of the superior turbinate and to a similar area opposite it 
on the nasal septum. 

The functions of the naso-pharynx are respiratory, to 
keep the throat moist by the secretion of mucus, to provide 
for the aeration of the middle ear through the Eustachian 
tube, and to act as a resonator for the voice. 

The pharynx, which is a continuation of the naso- 
pharynx, serves all the purposes of the naso-pharynx except 
that of ventilating the Eustachian tube, but in addition it is 
a part of the alimentary canal and conducts food into the 
esophagus. Parts of the nerve of the sense of taste are 
also distributed to the mucous membrane of the pharynx, 
so that it participates as an organ of the sense of taste. 
The larynx is an organ of respiration and of phonation. It 
receives the air, which is conducted from the larynx into 
the trachea. The larynx also furnishes mucus for the lubri- 
cation of its interior, and moisture and heat to the inspired 
air, but in a much less degree than the nose. It is also the 
organ for the production of voice. 

17 



258 



NOSE AND THROAT NURSING. 



The true vocal cords are the parts concerned in the 
formation of the voice. They are moved by eleven delicate 
muscles and are set in vibration like the reed of an organ 
by the air passing in expiration between them. The per- 
fection and pitch of the voice depend upon the perfect ad- 
justment of the cords. The quality of the voice depends 
upon the shape and size of the parts above the vocal cords, 
in the pharynx and in the nose. 



CHAPTEE II. 



PREPARATION FOR OPERATION. 

Local Anesthesia — Poisoning from Anesthetics — Prevention 
of Poisoning — General Anesthesia. Position and Preparation of 
Instruments and Apparatus: Illumination — Sterilization of In- 
struments. Preparation of Patient: Cleaning of External Parts 
— Cleaning of Nose — Douche — Cleaning of Mouth and Pharynx — 
Diet before Operation. 

Local Anesthesia. 

Operations on the nose and throat are sometimes done 
without anesthetics. We may assume that some method of 
alleviating the pain of operation will be used, either local or 
general anesthesia. 

Local anesthesia is produced by application of medi- 
cine to limited areas, producing temporary paralysis in the 
terminal sensory nerves at the seat of application. The 
anesthesia may be complete or incomplete, different reme- 
dies producing varying degrees of anesthesia. The use of 
heat or cold is well known in surgery, and in simple throat 
operations or in the absence of better means cold may be 
used for amputation of the tonsils or the uvula, for the in- 
cision of abscess, and as an application to diminish pain 
after operations. 

Heat is best applied by means of special apparatus 
which blows hot air into the nose or throat, or by a hot- 
water douche, the temperature of which should be greater 
than usual, 110°, 115°, or 120° F. 

To produce any anesthetic effect from hot water it must 
be hot enough to induce sharp sensation of burning, which 

(259) 



260 



NOSE AND THROAT NURSING. 



soon subsides and leaves the membrane upon which it was 
used somewhat anesthetic. 

Cold applied by douches of ice water, of a temperature 
from 38° to 40° F., in the nose or by pieces of ice held 
against the soft palate or tonsil or by icebag on the neck, 
produces a greater degree of anesthesia than heat, and its 
effects are more prolonged. Under the influence of cold, 
tonsillotomy, uvulotomy, and incision of abscess may be 
painlessly performed. Phenol-camphor, a mixture of % 
carbolic acid and % camphor, producing a non-irritating, 
colorless liquid, will induce sufficient anesthesia when ap- 
plied to the throat on a cotton pledget and probe, to perform 
short operations. It is used when for some special reason 
cocaine is contraindicated. Solutions of carbolic acid (10 
per cent.), menthol (4 to 8 per cent.), and the volatile oils 
are sometimes useful. Eucaine in 2, 4, or 10 per cent, 
watery solutions is, next to cocaine, the most useful local 
anesthetic. It is less stable than cocaine and its action 
is uncertain. It is used in a watery spray or on cotton 
pledgets. It is superior to cocaine only in laryngeal opera- 
tions, for here it does not contract the tissue and diminish 
the bulk of the operating field. In nose work it does not 
compare with cocaine in general usefulness or applicability. 
Eucaine does not, however, produce any poisonous or con- 
stitutional symptoms. Novocaine in solution df %, 1 or 
2 per cent is used injected into tissues and produces a satis- 
factory and safe anesthesia. It is said to be non-toxic. 

Cocaine anesthesia is obtained by spray, pledget, in- 
jection, and applications of the crystals of the drug. For 
anesthetic effects it is preferable to use watery solutions, 
as they are more diffusible. When oily solutions are used 
the alkaloid cocaine is used; not one of the salts. In 
watery solutions, hydrochlorate of cocaine is preferred. 



ANESTHETIC'S. 



261 



The most satisfactory effects are produced by using 
varying strengths of the watery solution. Solutions of from 
1 to 50 per cent, are used. Any degree of anesthesia may be 
induced. With a 1 per cent, solution anesthetic and con- 
tractile effects are produced in about three minutes. With 
stronger solutions the effect is observed quicker and the 
anesthesia is more profound. Total absence of all sensation 
is not possible. Patients are always able to feel the oper- 
ating instrument upon the anesthetized part, so that pa- 
tients insist that they experience a certain degree of sensa- 
tion. It is certain that they suffer no pain. The duration 
of anesthesia depends upon the length of cocaine contact 
and the strength of the solution employed. 

It is well to remember that the action of cocaine is 
strictly local and confined to the area to which the cocaine 
has been applied, and the slightest touch beyond this region 
produces pain. A thoroughly applied 4 per cent, solution 
will cause anesthesia for about three minutes, an 8 per cent, 
solution for about six minutes, and sometimes a 20 per 
cent, solution for a half-hour. Besides producing anes- 
thesia, the cocaine shrinks all soft tissues by contracting the 
blood-vessels ; this decrease in the quantity of blood dimin- 
ishes the size of the tissue. It is well to remember this 
lessening of bulk, of at least one-half. Complete anesthesia 
for a long period could easily be produced were it not for 
one drawback — the production of general constitutional 
symptoms, which are unfavorable to the patient's welfare 
and are sometimes dangerous. These unfavorable omens 
indicate absorption into the general circulation of enough 
cocaine to produce poisonous symptoms. The earliest signs 
are a desire to talk, a lightheartedness, and a sense of well- 
being. The physician notices a brightened eye, an acceler- 
ated movement, and a quickened pulse, which becomes fuller 



262 



NOSE AND THROAT NURSING. 



and increases in tension. At this stage, if the area of local 
application be examined it will be found blanched and en- 
tirely anesthetized. The increasing pulse-rate and tension 
are useful to indicate the complete anesthesia of the part 
desired, and the moment of complete anesthesia can be de- 
termined without local examination. If any cocaine flows 
over the upper surface of the soft palate or down the lateral 
pharyngeal folds, nausea and gagging are induced. A very 
common disagreeable symptom is a "ball in the throat." 
After the advent of these first indications of discomfort, in 
some cases, the cocaine ceases to produce other. But in a 
few people the unfavorable symptoms develop rapidly from 
this stage. The patient's face becomes pallid; the eyes 
dulled; there is a sense of extreme exhaustion and muscular 
relaxation, with a very rapid and weak pulse ; nausea is in- 
duced ; and the patient becomes apprehensive and restless, 
breaks out with a profuse, cold perspiration, and is unable 
to maintain the erect position. If the depression of the 
nervous system continues, the heart fails to act and the 
patient faints. After recovering from these acute symp- 
toms, the patient remains weak, anxious, and nervous for 
twenty-four hours. 

Prevention. — These unfavorable constitutional effects 
of cocaine may be prevented, or, in case they develop, may 
be suppressed by the administration of some diffusible car- 
diac stimulant. If these stimulants are used before cocain- 
ization the symptoms rarely develop. Whisky, q.s. ; nitro- 
glycerine solution, 1 per cent., 3 minims ; tincture of dig- 
italis, tiivi-x; aromatic spirit of ammonia, nixv, used alone 
or, better, in combination, are extremely useful. A good 
formula to be given before cocaine is employed and one I 
generally give as routine is : — 



ANESTHETICS. 



263 



B Sol. nitroglycerin, 

Ext. digitalis fl aa n^ij. 

Spts. frumenti 3 SS - 

The nausea and gagging and frequently the vomiting are 
prevented by peppermint-water gargle or by an oily menthol 
spray in the pharynx. If fainting ensues, the prone posi- 
tion, with the head lower than the chest, and the use of the 
above-mentioned cardiac stimulants will in a few moments 
restore the circulation. 

Morphine sulphate (% grain) administered hypoder- 
mically is a fairly sure remedy to prevent toxic symptoms 
from cocaine if used one-half hour before the cocaine is 
used. It is also an antidote to the poisonous symptoms 
when they develop. As routine practice we give morphine 
sulphate % grain to every case which is to have cocaine 
anesthesia and we never see cocaine poisoning. This is true, 
however, only when the cocaine is not injected. 

General Anesthesia. 

Nitrous oxide (laughing gas) anesthesia is not often 
employed in throat cases except in adenoid operations. It 
requires no special mention except to note that the mouth- 
gag must be introduced before the inhalation begins. The 
anesthesia is completely produced in sixty seconds, is not 
followed by any unfavorable symptoms, and is, in fact, the 
best form of anesthesia to use. 

In ether and chloroform anesthesia there are a few 
points differing in its application to general surgery which 
the nurse must remember. No class of patients take anes- 
thetics so poorly as children suffering from adenoids and 
enlarged tonsils. In these patients the nasal respiration is 
scarcely used, and in the early stages of ether rigidity 
the mouth and teeth are firmly fixed. As a result, these 



264 NOSE AND THROAT NURSING. 



cases breathe badly and cause some anxiety from restless- 
ness and cyanosis. Frequently the jaws must be pried open 
and the gag introduced, or the tongue seized with the tongue 
forceps, or dragged forward by means of a silk thread 
passed through it. During and after the operation the pro- 
fuse bleeding interferes with respiration. Loose blood-clots 
fill the pharynx and are sometimes inspired, or cover the 
epiglottis and larynx. This complication is prevented by 
operation with the head hanging over the table (see Fig. 
23) and by carefully cleansing the mouth. 

I have always proceeded with my operations until 
fairly certain that blood has entered the larynx and respira- 
tion is impeded. Then I quickly draw the patient's head 
over the end of the table and by rapid finger strokes upon 
the trachea and then the larynx, which is quite compressible 
in children, force the clots again to the mouth. Of course, 
this larynx stripping must be done from the sternum toward 
the mouth, and not the reverse. It is a valuable procedure. 
Food articles are expelled in the same way (Fig. 32). 

Except for these particulars, the general rules for ether 
and chloroform anesthesia apply to nose and throat opera- 
tions. 

The operations must not be commenced in nose and 
throat work until the patient is profoundly anesthetized, 
the conjunctival sensitiveness entirely abolished, — for the 
profuse bleeding both from nose and throat operations often 
interferes with the further inhalation of ether and chloro- 
form, — and the patient may become conscious before the 
operation is completed. 

Position and Preparation of Instruments and 

Apparatus in Operations. 
Illumination. — For operations where cocaine is used, 
» the patient sits erect in a chair, the nurse steadies the head 



OPERATIONS. 



265 



with the hand placed at the occiput, and the operator sits 
in front of the patient with both the patient's knees between 
his. The light, best from a condenser, should burn 8 inches 




Fig. 23. — Position of Patient with Head Hanging 
over End of Table. 



from the patient's shoulder, on a level with his ear. In com- 
plete narcosis, the position upon the back on the operating- 
table is preferable. In adenoid operations, the head should 
be lower than the body (see Fig. 23). 



266 



NOSE AND THROAT NURSING. 



In ether or chloroform narcosis reflected light for the 
head-mirror is obtained best from an electric bulb either as 
a headlight or held by the nurse 8 inches away from the 
patient's head, on a level with the top of the ear. There is 
a certain danger of fire from using gaslight near the ether 
cone, but I have found it quite safe at a distance of 1 foot 
from the ether cone if a closed inhaler is used. With chlo- 
roform there is no danger from flame. 

The sterilization of instruments differs in no 
manner from the ordinary surgical procedure. Heat or 
compressed steam are the best methods, although formalde- 
hyde gas is much used. The simplest sterilization is boiling 
for fifteen minutes in a vessel which has previously been 
wiped out with a bichloride solution, 1 to 1000. The boil- 
ing water should contain a quantity of sodium carbonate 
(5j-Oij). A simple and effective way to sterilize instru- 
ments that have been soiled is, as the operator uses them, to 
smear the surface with albolene and hold it for a moment 
over the chimney of the Argand condenser used for illumi- 
nation. The albolene liquefies and then evaporates at 
such a low temperature that the instruments are quickly 
sterilized without injury to the temper of the cutting edge. 
Instruments should be used dry, and not submerged in trays 
of antiseptic solutions. 

Towels, sheets, and gauze used in the operation may 
be boiled and dried, or, better still, sterilized by compressed 
steam. (See pages 218-220.) 

Vessels, trays, or dishes of any kind should be cleaned 
with soap and hot water, washed in boiling water, and dried. 
All vessels should be covered witJi a bichloride towel. 

Rubber sheets, rubber splints, articles of cork, and 
other material injured by boiling should be washed with 
soap and water and afterward immersed in a formaldehyde 



OPERATIONS. 



267 



solution, 1 to 100. Such articles may also be sterilized by 
dry heat. 

The nurse should carefully sterilize her hands once, 
afterward dipping them freely in a bichloride solution, 1 to 
1000. She must remember to keep the hands sterile, for one 
moment she assists at the operation and the next may be 
required to handle some article, lamp, etc., which has not 
been rendered aseptic. A towel wet with a bichloride solu- 
tion, 1 to 5000, must be the constant companion of the 
nurse, thrown over her arms when she handles articles ster- 
ilized and used to cover any article which is not sterile 
when it is to be removed. In this way the nurse's hands 
never come in contact with germ-laden articles, but only 
touch the sterilized and wet towel placed about . the unclean 
article. 

The sterilization of the hands of the nurse is a 
matter of extreme importance, and is equally important 
with clean instruments and an aseptic surgeon. There are 
two satisfactory methods of cleaning the hands : — 

First. — The chloride of lime method, advocated by Dr. 
TL Wier, consists of scrubbing the hands with a clean brush, 
water and green soap, carefully cleansing around the finger- 
nails with a wooden toothpick soaked in an antiseptic solu- 
tion. After this, a paste is made in the palm of one hand 
w T ith a little water, some small crystals of carbonate of soda 
(washing soda), and an equal quantity of chloride of lime 
.(bleaching powder). This paste evolves chlorine gas, an 
efficient antiseptic, while the alkali removes all trace of fat 
and the dead epithelium. Carefully wash the hands with 
this paste and afterward in sterilized water. Cultures made 
from hands cleansed by this method have never shown any 
germ growth. 



268 



NOSE AND THROAT NURSINO. 



Second. — Permanganate of potash and oxalic acid 
method : In this method the hands are carefully scrubbed 
with water and green soap and the nails prepared as in the 
preceding method. The hands are then immersed in a solu- 
tion of permanganate of potash — strength, 1 to 1000 — for 
two minutes (sometimes a saturated watery solution of per- 
manganate is used), and afterward rinsed in a solution of 
oxalic acid until the hands are perfectly white. This also 
renders the hands absolutely sterile. 

Sterilization of Rubber Gloves. — Nowadays it is 
customary for both doctors and the nurse who assists in the 
operation to wear rubber gloves. The sterilization of the 
gloves is a matter of the greatest importance. There are 
three methods which may be used. 

First Method. — The gloves -whether old or new are 
thoroughly scrubbed with green soap, hot water, and a 
sterile hand brush, they are turned inside out and scrubbed 
also. Then they are rinsed in water and allowed to dry 
both inside and outside by turning. The gloves are now 
tested for holes by blowing them full of air and noting that 
there is no escape of air from the inflated glove. They are 
now assorted as to size and powdered with talcum inside 
and outside. Then they are again tested for holes by in- 
flation and put in cotton cloth cases or glove holders. They 
are now packed with their cases in a metal drum the cover 
of which is unlatched and the vents opened. The drum con- 
taining the gloves and cases is now put in the steam 
sterilizer where they are exposed to live steam under 15 
pounds pressure for twenty minutes. The vent of the 
sterilizer is now opened, the sterilizer and contents allowed 
to dry. Then the drum containing the gloves is closed and 
removed. 



OPERATIONS. 



269 



Second Method. — The gloves both old and new are 
scrubbed with green soap, water, and a hand brush (both in- 
side and outside are cleaned), then they are rinsed in clean 
water and are now transferred to another clean water in 
which they are boiled for ten minutes. A table is now 
covered with a sterile sheet on which are placed sterile glove 
containers of cotton cloth, also sterile talcum powder and a 
sterile towel. The gloves are transferred from the boiling 
water by means of a pair of sterile forceps to the table. 

The nurse covers them with a sterile towel. The nurse 
now sterilizes her hands after one of the methods mentioned 
on page 267, and places the dried gloves in the cotton con- 
tainers after the gloves have been powdered inside and out- 
side with talcum. 

Third Method. — Emergency method. After the gloves 
have been tested by inflation to see that there are no pin- 
holes, they are scrubbed inside and outside with soap and 
water, rinsed in clean water and boiled for ten minutes in 
plain water. They are taken from the sterilizer with sterile 
forceps, put upon a table covered with a sterile sheet and 
used at once. 

In a hurry — a real emergency, they may be tested for 
holes, sterilized by boiling for ten minutes and used at' 
once. 

Preparation or the Patient. 

Besides looking after the operating room and the ster- 
ilization, the nurse is expected to prepare the patient for 
operation. Some rhinologists claim that the nose is itself 
destructive to germs because lymph exuding upon the free 
surface of the nasal mucous membrane is antiseptic. I do 
not doubt this, but conditions are altered whenever we 
produce a wound of the nasal tissues, for here the lymph 



270 



NOSE AND THROAT NURSING. 



does not act, and a bacteria-laden nose will infect a fresh 
wound very quickly. The nose cannot remain sterile for a 
long time, for it is liable to contamination from inhaled 
microbes, as well as infection from the postpharynx and 
from septic matter in the many folds of the nasal mem- 
brane which it is impossible to reach with cleansing meth- 
ods. But much may be done to have the nose and throat 
nearly free from germs or anything that might act as a 
culture medium after operation. 

In operations upon the nose the nurse should first pre- 
pare the patient by cutting away with scissors the short 
hairs growing inside the nasal entrances. The nose is then 
washed either by a spray or an ear syringe with a mixture 
of peroxide of hydrogen and water, strength 1 to 4 or 1 to 
10. After several injections, using perhaps 2 ounces of the 
mixture, the patient should receive a nasal douche, and, 
after the nose is dried by forced expirations or gentle blow- 
ing, a piece of cotton should be introduced into the entrance 
and removed by the surgeon at the time of operating. It 
is not necessary to shave the upper lip of a patient unless 
some operation is to be performed which involves cutting 
this region. A mustache should be carefully washed with a 
bichloride solution, 1 to 1000. 

Tincture of iodine (one-half strength of 3% per cent.), 
may be painted over the face, also inside the nostril and 
over the field of operation. It is then removed by alcohol 
and leaves a sterile field. It is also an effective method of 
sterilization of mustache. For the nasal mucous membrane 
iodine should not be used. For the interior disinfection 
argyrol 20 per cent, is efficacious. 

The nasal douche must be used exactly after the 
manner which will now be described, or else fluid will re- 
main in the nose or will be forced through the Eustachian 



NASAL DOUCHE. 271 

tubes into the middle ear, where it is apt to cause middle 
ear disease ; or fluid may be forced into the antrum of High- 
more or the frontal sinus, where it may set up a catarrhal 




Fig. 24. — Method of Using a Nasal Douche. (Note position 
of the head and height of douche bag.) 

inflammation. The douche is given with a fountain bag 
fitted with the nasal tip (see Fig. 24) filled with water, 
which should be hot— from 108° to 112° F. Water at 
110° in the bag will flow from the nozzle into the nose at 



272 



NOSE AND THROAT NURSING. 



107°, and after flowing through both nostrils emerges from 
the opposite side at 105°. Water at 110° is warm to the 
nose, at 114° to 116° is hot, and at 120° is hemostatic. To 
each quart of water, 1 drachm (teaspoonful) of salt should 
be added to render it non-irritating. Antiseptics are added 
in such strengths as will not irritate. Practical experience 
has shown that in the nose and throat tissues antiseptics 
must be used well diluted. The ordinary drugs may be used 
in the following strengths in douches: — 



Sodium chloride 1: 1,000 to 1: 250 

Sodium bicarbonate 1 : 1,000 to 1 : 500 

Borax (sodium borate) 1: 1,000 to 1: 500 

Boracic acid 1 : 1,000 to 1: 500 

Sodium salicylate 1: 1,500 to 1:1,000 

Potassium permanganate 1 : 5,000 

Zinc permanganate 1 : 5,000 

Zinc chloride 1: 10,000 

Mercury bichloride 1:100,000 

Formaldehyde (40 per cent, solution) . 1:100,000 



After the douche has been prepared it is held 6 inches 
above the patient's head, the water is allowed to run out at 
the nozzle until warm, and then the nozzle is put into the 
patient's nose on the highest or uppermost side. The pa- 
tient should hold the head well bent upon the shoulders, 
over a basin, and all respiration must be accomplished 
through the open mouth. 

The head must be bent so that one side of the nose is 
lower than the other side (see Fig. 25). The water will 
flow gently through one side into the postpharynx. In a 
second afterward it returns through the other nostril and 
flows into the basin. 

After one side is thoroughly irrigated the head is 
turned so that the formerly lower side becomes uppermost. 
The water now enters this side and flows out the other. In 



NASAL DOUCHE. 273 

this way the nose is completely cleared of all dust, mucus, 
and pus. In following this method no solution will enter 
the Eustachian tube or the nasal sinuses. The patient is 




Fig, 2'k — Nasal Douche Given with a Bulb. (Note 
position of patient's head.) 

now allowed to blow the nose gently several times till it is 
entirely cleared, and then one pledget of clean cotton ia 
placed at the entrance of each nostril to prevent further 
contamination until the anesthetic is administered. 

18 



274 



NOSE AND THROAT NURSING. 



The mouth and pharynx must next be cleansed. A 
careful disinfection of the mouth is important in some op- 
erations, particularly those upon the tongue, lip, or soft or 
hard palate. The best solutions to use for the purpose are 
boracic acid, peroxide of hydrogen, permanganate of potash, 
or formaldehyde. The teeth must be cleansed by scrubbing 
with a toothbrush wet with the solutions, and each crevice 
between the teeth and gums must be washed; the mouth 




Fig. 26.— Applicators Wound with Cotton. The 
middle one is wound correctly. The right hand one 
incorrectly, for the end of the applicator projects be- 
yond the cotton. The one at the left is too bulky at 
the end. 

. must be cleansed by frequent garglings, and the surfaces 
between the lips and gums as well as those between the 
tongue and teeth carefully cleansed with cotton pledgets 
dipped in the chosen antiseptic solution. The soft palate, 
uvula, tonsils, and posterior pharyngeal wall must be 
scrubbed gently with cotton soaked in antiseptic Solution 
and wound on applicators. 

There is a right and a wrong way to wind applicators 
with cotton, which may be spoken of in this connection. 



NASAL DOUCHE. 



275 



The end of the applicator must be well surrounded by loose 
cotton and must never project so as "to injure the delicate 
tissues of the nose and throat. The free end must be loose, 
the other end wound firmly upon the applicator as it is 




Fig. 27. — Method of Making a Cap from a Towel. 



turned between the fingers. The free end of the cotton will 
then form a pad which for nose work should be rather large 
and very soft, as shown in Fig. 26. 

A rubber cap may be placed upon the patient's head to 
cover the hair when everything is ready for the operation. 



276 



NOSE AND THROAT NURSING. 



If a rubber cap is not obtainable, a sterilized towel well 
pinned will answer nicely. This serves a double use : pre- 
vents infection of the surgeon's hands, and protects the hair 
from blood, which, when clotted among the hairs, especially 
with women, is difficult to remove (Fig. 27). 

THE DIET BEFORE ETHER OR CHLOROFORM OPERATIONS. 

Patients should have no solid food for twelve hours 
before the operation. Some liquid nourishment, best in 
the form of bouillon, beef-tea, beef-juice, tea, or coffee, may 
be given six hours before the operation. Not even a glass 
of water should be allowed for the six hours preceding 
etherization. The bowels should be evacuated by enema or 
a laxative the evening before the operation. 



CHAPTER III. 

CARE OF PATIENT DURING AND AFTER OPERATION. 

Hemorrhage — Vomiting of Blood — Headache and Stupor — 
Sepsis. Operations Requiring Special Care: Adenoid Operation 
— Cleft Palate Operation — Tracheotomy — Fissure of Larynx, etc. 

Cake of the Patient During the Operation. 

There are duties which are entirely the nurse's during 
operation, and preparations must be previously made to 
meet them. The nurse is expected to attend closely to the 
number of pledgets of cotton used during the operation, 
either on applicators or on forceps, to count these pledgets 
and see that all are removed by the surgeon, who may forget 
this trifle in the interest excited by the more important part 
of the operation. A cotton pledget left in the nose, if 
tucked up behind a turbinated bone, soon ceases to be a 
trifle, for it acts as a foreign body, becomes septic, and in 
turn causes sepsis, hemorrhage, or purulent discharge. 

The nurse must also keep her mental eye upon the 
small sponges used to cleanse blood from the pharynx, and 
see that none remain in the mouth. A bottle containing a 
1 per cent, solution of formaldehyde should be used to hold 
the tissues removed by operation, and the nurse should pre- 
serve these at once in this solution. They are then ready 
for the surgeon's study or the pathologist's knife. 

In adenoid operations the nurse must watch the mouth- 
gag, observe that it is not shaken from its position on the 
teeth, and, if reintroduced during the operation, that the 
lip border does not become entangled in the gag. 

(277) 



278 



NOSE AND THROAT NURSING, 



In tonsillotomy the cut tonsil must be removed, and if 
lost must be searched for at once in the mouth of the pa- 
tient; else it may enter the larynx and obstruct the 
breathing. 

Blood or" mucus flowing over the conjunctival surface 
of the eyeball will cause an acute conjunctivitis; and one 
of the duties of the nurse is to keep this blood and mucus 
out of the eyes by carefully cleansing the blood from the 
face or by holding a towel over the eyes during the bleed- 
ing. Pledgets of moist cotton are sometimes placed over 
the eyes and held by the towel cap placed about the head. 

If blood or mucus is inspired into the larynx or trachea 
during an operation, it may cause strangulation or after- 
ward an acute bronchitis or broncho-pneumonia. A part 
of the nurse's duty is to prevent this by handling sponges 
quickly, by holding the head of the patient lower than the 
body, or, if the blood or mucus has entered the larynx and 
the patient exhibits cyanosis, the nurse must "strip" the 
larynx (Fig. 32, page 327). A tracheotomy set must al- 
ways be ready for possible use in this emergency. 

Care of Patient After Operation. 

Very important duties, indeed, are those of the nurse 
after an operation has been performed. A good nurse must 
now be prepared to meet emergencies and to treat them 
understandingly, else valuable time may be lost and the 
patient becomes much devitalized before the surgeon can be 
summoned. In operations generally, but especially in nose 
and throat work, a physician other than the operator, called 
in for any emergency, may work with doubt and hesitancy, 
because he is not wholly familiar with the conditions in the 
case before him. Especially may this be true in hemorrhage 
or after septum operations. The nurse must recognize and 



DUTIES DURING AND AFTER OPERATION. 279 

control the complications which are apt to arise after opera- 
tion, viz. : hemorrhage, reaction, disturbance of parts, vom- 
iting of blood, headache, stupor, and sepsis, watch the tem- 
perature and pulse, and administer the proper diet. 

Hemorrhage. 

Moderate bleeding from the nostrils may occur for 
hours without any danger of exsanguination. If the bleed- 
ing is more active, running out of the nostril in a continu- 
ous stream, immediate measures must be taken to check it. 
A steady stream of blood is generally present when some of 
the venous sinuses have not filled with a clot or from a 
septal arterial branch having been wounded. Sometimes 
even the simplest measures will check an alarming hemor- 
rhage. The popular belief seems to be that all nose-bleeds 
are of considerable seriousness, and patients are apt to be- 
come very anxious if the bleeding continues. Bleeding 
through the nose is, of course, easily recognized, but when 
patients are lying upon the back, bleeding, even though it 
be very active, is sometimes overlooked because the blood 
flows from or into the pharynx and is swallowed. The nurse 
must inspect the pharynx of patients who have been op- 
erated upon. If hemorrhage occurs the blood may be gen- 
erally seen flowing quite actively from the operated side. 
If the patient is still unconscious from ether and hemor- 
rhage is feared or suspected, the case should be rolled upon 
the side or abdomen and the head placed lower than the 
shoulders. Immediately, if there is any hemorrhage, blood 
will flow from the mouth and" nose. If this precaution is 
neglected in unconscious patients, an active hemorrhage 
may be present, and all the blood swallowed, then the first 
evidences will be syncope, or the loss of blood may be so 
great that patients suddenly become very pale and imme- 



280 



NOSE AND THROAT NURSING. 



diately after vomit alarming quantities of blood. They 
may even become so exsanguinated that transfusion is 
necessary. 

A nasal hemorrhage, even when severe, may very fre- 
quently be checked by making pressure inward against the 
septum with the ball of the thumb resting flat upon the 
wing of the nose with the patient's head well bent forward. 
If the pressure is steady and for a considerable period (from 
five to ten minutes) very severe bleeding will be controlled. 
At first the blood will flow around the septum and out 
through the opposite nostril. Gradually a clot will form 
and the bleeding will cease. Sometimes the blood will clot 
in both nostrils and will then flow into the pharynx and out 
of the mouth. If the pressure is continued the bleeding 
ceases soon after this has occurred. An icebag may be ap- 
plied to the nape of the neck to stimulate the -contraction of 
the nasal vessels It is a valuable supplement. 

If, after ten minutes, the bleeding has not ceased or 
in a shorter time if the bleeding is active, other methods 
must be used. These are: (1) the cotton plug; (2) hot- 
water douche; (3) peroxide of hydrogen; (4) extract of 
suprarenal glands or adrenaline; (5) complete plugging; 
(6) .posterior nasal tampon. 

If these are used in the order named, some one of them 
will completely control bleeding. 

The cotton plug is made of absorbent cotton wound 
loosely upon a probe or applicator, about 2% inches long 
in a cylindrical form. This plug is used dry or saturated 
with peroxide of hydrogen or a solution of aceto-tartrate of 
aluminum, and is pushed directly backward into the nostril 
its full length. The metal applicator is now withdrawn, 
leaving the plug in place, its end slightly protruding from 
the nose. 



NASAL HEMORRHAGE. 



281 



If the hemorrhage is not checked by these procedures 
the ping must be withdrawn and styptic measures used. 
There are only fou? styptics safe to use in the nose, namely : 
peroxide of hydrogen, hot water (125°), solution of aceto- 
tartrate of aluminum (1 to 8), and watery extract of the 
suprarenal glands or an alkaloid solution of the suprarenal 
glands. The hot-water douche (125°) is used as described 
in Chapter II, pages 270-274, of this part, the peroxide of 
hydrogen with an ordinary syringe or spray, the suprarenal 
extract in a spray, and the aceto-tartrate of aluminum is ap- 
plied by spray or on a cotton plug. All other styptics are 
corrosive, and should never be used. Iron especially is to be 
avoided, for it, with other stronger styptics, is caustic, and 
leaves the mucous membrane in a very irritated, congested, 
and even ulcerated condition. I wish to except here certain 
caustics which may be used by the physician to control 
hemorrhage when applied to the pleeding point with great 
care. 

The Xasal Plug. — To completely plug the nostril, 
cotton pledgets on applicators may be used and several small 
plugs introduced in different directions into the bleeding 
side. The first plugs should be introduced well back, the 
next ones pushed high up, then several pledgets may be 
placed in front of these until the nostril is completely filled. 
A careful count must be made of the number of plugs intro- 
duced to insure removal of the entire number later, for any 
left behind will cause serious annoyance from discharge and 
sepsis. It is not always easy to find these pledgets tucked 
away in the folds of the mucosa and covered with blood and 
mucus. 

An approved method is to use one long strip of anti- 
septic gauze about % inch wide, introducing it well back- 
ward for 2Y 2 inches low down on the nasal floor, and then 



282 



NOSE AND THROAT NURSING. 



pack above and in front of this until the nostril is com- 
pletely filled. The end sticking from the nose is easily 
found and no difficulty arises from any pieces being left, for 
it all comes away in one strip. The loose meshes of the 
gauze cause a more rapid entanglement and clotting of the 
blood. Medicaments may be used on the gauze as on the 
cotton. 

The postnasal tampon is the last resort, and will 
surely stop the hemorrhage. A nurse will rarely use it, but 
should have every part of the plug ready for the surgeon's 
use. She should understand what is to be accomplished, for 
valuable aid may be rendered the surgeon. The postnasal 
plug is applied by passing a string, rubber tube, or English 
catheter through the bleeding side of the nose, pulling the 
string, tube, or catheter through the mouth ; to this another 
doubled string is tied holding the plug; by drawing this 
double string through the nose the plug follows to the uvula 
and is easily pulled into the postpharynx behind the uvula 
aided by manipulation with the fingers. The nose is then 
packed with gauze and at the anterior nasal orifice a second 
plug is tied with the projecting double string, and effectively 
holds both plugs — the anterior and posterior — in firm posi- 
tion. If a catheter is used it should not be too flexible. A 
heavy string or tape is passed looped through the entire 
length of the catheter. The loop should be waxed to prevent 
softening with saliva and subsequent difficulty of manipula- 
tion. From the eyelet end, the loop should project 3 inches ; 
from the open end, the loop should project the length of the 
catheter. The plug should be firmly rolled and large 
enough to fill the whole postpharynx. In an adult male, 
iy 2 inches by 1 inch in diameter is the usual size. A double 
string or tape is tied around the middle of the plug. The 
strings should be 8 inches long; they are tied on the tape 



THE POSTNASAL TAMPON. 



283 




Fig. 28.— Postnasal Plug. 



Left hand figure shows the plug 
and double string. Right hand fig- 
ure shows the catheter with string 
running through it. 




Fig. 30— Postnasal Plug. 



The catheter w'thdrawn and the 
string pulled through mouth and 
tied to the large cotton plug. 




Fig. 29.— Postnasal Plug. 



Section of a head showing first 
step of plugging, the catheter and 
string passed through the nose to 
the pharynx 




Fig. 31.— Postnasal Plug. 

The plug is now in place, hav- 
ing been pulled there by the string 
aided by pushing it with the fin- 
gers in the mouth. 



284 



NOSE AND THROAT NURSING. 



or string coming through the nose, pharynx, and mouth, the 
plug being pulled into place by traction. Usually a third 
string is used on the plug for purposes of easy removal ; but, 
as this string is a continual source of annoyance to the pa- 
tient, it is better left off and the plug removed when 
necessary with a pair of adenoid forceps. 

Every tiling being in readiness, the patient is allowed 
to irrigate the nose and throat with DobelPs solution or any 
antiseptic wash. While this temporarily increases the 
hemorrhage, it is of great use in cleaning the parts, and 
thereby allows the retention of the plugs a longer time 
without sepsis. With a good light reflected into the pa- 
tient's nares and pharynx, the catheter, oiled and threaded 
as above described, is introduced through the bleeding side 
into the pharynx, where the stiffened wax loop is easily 
drawn through the mouth with forceps and held firmly 
against the teeth while the catheter is withdrawn, leaving 
the waxed loop running through nose, throat, and mouth. 
To the loop in the mouth both the plug strings are firmly 
tied and the plug is pulled in place in the postpharynx, its 
course being over the tongue and behind the uvula. It is 
guided into place by the index finger of the left hand. As 
it reaches the postpharynx the tendency of the plug is to 
fold or else enter endwise. This must be controlled or the 
pharynx will not be completely plugged. The plug should 
enter the pharynx crosswise or horizontally, and must be 
firmly pulled forward toward the nose so as to fill com- 
pletely the posterior nasal opening and prevent further exit 
of blood. The pulling must be continued until the plug is 
well jammed into the posterior nares and naso-pharynx 
and is out of the way of the movement of the uvula. The 
two strings coming through the nose from the plug are now 
separated and gauze is packed between them. When the 



THE POSTNASAL TAMPON. 



285 



naris is moderately filled another plug is introduced into 
the anterior naris, completely filling it, and the two strings 
are tied tightly over the anterior plug. As the strings are 
tightened, the anterior plug will enter the nose and a 
second knot may he tied over the first one. The nose is now 
thoroughly plugged. The hemorrhage will cease at once. 
Failure to check bleeding generally results from a plug, 
posterior or anterior, which is too small, or else from 
neglect to pack the nasal cavity with gauze. The plugs very 
soon become wet and slimy and slip easily if they are not 
firmly pulled into place and securely tied. If the plugs 
are satisfactory they need not be removed for forty-eight 
hours or longer, the indication for their removal being 
sepsis or pain in the ear. If hemorrhage continues, the 
plugs must be removed and new ones introduced of larger 
size. 

The removal of the plug is accomplished by cutting the 
thread over the anterior plug, removing the anterior plug, 
and allowing the gauze to remain undisturbed. Adenoid 
forceps gently introduced behind the uvula will grasp and 
remove the posterior plug easily, and obviate the danger 
that the plug may be swallowed. The gauze may be left in 
place for another twenty-four hours, and great care should 
he exercised when it is removed. It must be thoroughly 
loosened by a douche of peroxide of hydrogen so that the 
recently bleeding point may not be freshly torn open and 
hemorrhage recur. 

The different stages are shown in the illustrations on 
page 283. 

Reaction After Plugging the Nose. — Under the 
term reaction is understood those constitutional symptoms 
which appear within the first twenty-four hours following 
an operation. They are generally inflammatory or con- 



286 



NOSE AND THROAT NURSING. 



gestive in character and vary somewhat in severity in in- 
dividual patients. In some patients reaction is always 
marked; in others no symptoms follow even a severe 
wounding of the mucous membrane. It may be stated 
that, as a rule, reaction symptoms are greater from cautery 
or drill operations than from surgical incision. In very 
sensitive people reaction may appear a few hours after oper- 
ation, or in less sensitive persons it may be delayed or 
altogether absent. The symptoms are those of a beginning 
"cold" : headache, chilliness or even a chill, febrile move- 
ment, exhaustion, and prostration. Usually, there are 
marked muscular pains in the legs and arms and local nasal 
symptoms of swelling, obstructions, heat, and discharge. 
Under appropriate treatment the reaction symptoms are 
controlled and subsequent sepsis often prevented. 

Treatment. — Eemoval of plugs is indicated, followed 
by a careful cleansing of the parts with peroxide of hydro- 
gen solution (1 to 20), followed by a douche of Dobell's 
solution or of normal saline solution. A soothing gargle or 
nasal salve may be prescribed by the physician. In pharyn- 
geal cases an iced gargle of alcohol and water, 1 to 10, or 
witch-hazel gargle, also iced, gives great relief. The head- 
ache, fever, and muscular pains are relieved by aconite and 
belladonna in small and frequently repeated doses or by the 
use of the coal-tar preparations: phenacetin, acetanilide, 
and antipyrin. A tablet of salol and phenacetin (aa gr. ij), 
used half-hourly, will give speedy relief and will in many 
cases prevent the development of septic symptoms if used 
immediately after the operation and before reaction ap- 
pears. 

The same reaction symptoms may occur later, when 
they are probably septic, but there seems no reason to 
-assign these early symptoms appearing the first day after 



DISTURBANCE OF PARTS. 



287 



operations to a septic condition. If reaction symptoms are 
pronounced and do not yield readily to the above treatment, 
the patient should at once be placed in bed. In a few cases 
meningitis has been a complication of nasal operations, 
and this must always be borne in mind. Cases with much 
headache should have ice applied to the forehead and ice 
cloths laid over the nose and face. These should be renewed 
often enough to keep the parts refrigerated. 

Serum Treatment for Hemorrhage. — Horse serum, 
20 c.c. in adults, 5 to 10 c.c. in children, is used by hypo- 
dermic injection into the muscle over the scapular region as 
a method to increase the coagulability of the blood. It is 
a very useful procedure. In very serious cases human 
serum from a pregnant woman has been known to be an 
efficient coagulating remedy when other plans failed. Only 
the serum from glander-free horses or from syphilis-free 
women should be employed. 

Calcium lactate, gr. v, each four hours, by mouth, is 
used also as an adjuvant to the serum treatment. 

DISTURBANCE OF PARTS. 

Careful watching is required in plastic work to prevent 
a return df the deformity for which the operation was per- 
formed. Nasal splints used in septum casesi should be re- 
tained without protrusion. In case the splint fits improp- 
erly and tends to be forced from the nose, it can be held, 
until the physician adjusts it, by a piece of adhesive plaster 
passed over the protruding end and fastened on each side of 
the nose. After a week, the only danger of septum de- 
formity returning exists from the accidental rolling upon 
the nose while in bed. Care will control this accident. In 
operations affecting the nasal bones, after their replacement 
the bandages must be given the closest attention and any 



288 



NOSE AND THROAT NURSING. 



deformity must be immediately corrected as soon as the 
slightest displacement is noticed. 

VOMITING OF BLOOD. 

This is a usual occurrence after any operation upon 
the nose and throat requiring an anesthetic. In septum 
cases or in the removal of adenoids or tonsils the bleeding 
is generally profuse during the operation and large quan- 
tities of blood are swallowed by the patient only to be ex- 
pelled by vomiting after consciousness returns. The vom- 
iting of this blood is apt to be alarming to the untrained 
attendant and even to the nurse, especially if the case has 
shown any tendency toward hemorrhage during or after the 
operation. This blood is expelled from the stomach rather 
suddenly by projectile vomiting, and is preceded by a 
period of marked cardiac depression. The face becomes 
pale, the prostration extreme, and the heart-action and 
pulse scarcely perceptible ; and, while these symptoms are 
marked and simulate exactly the extreme collapse caused 
by bleeding, the vomiting of the swallowed blood suddenly 
occurs to add to the anxiety of the nurse. The true state 
of affairs is soon revealed, for after the vomiting of this 
blood the condition of the patient improves and anxiety 
gives way to satisfaction. Sometimes the entire quantity 
of blood in the stomach is not expelled at one vomiting 
attack, in which case the period of collapse is prolonged and 
is succeeded by a second vomiting attack, in which the en- 
tire stomach contents are expelled, to be immediately fol- 
lowed by improvement in the general condition. When this 
collapse is prolonged it is important to know whether or 
not the hemorrhage has ceased entirely. If the hemorrhage 
is continuous, it may be recognized in unconscious and 
anesthetized patients by noting any attempts to swallow. 



SEPSIS. 



289 



If such are present, the probabilities are that the hemor- 
rhage continues, and the pharynx must be inspected at 
once. If the blood is not entirely vomited it passes on to 
the intestines, and several black, bloody stools will be 
noticed the following day. Sometimes a part of the blood 
is vomited and the remainder passed per rectum as bloody, 
diarrheal stools. 

HEADACHE, STUPOR, AND SEPSIS. 

Headache after operations is due to reaction, fever, 
inflammation of local parts, and sepsis, or to the pressure 
from plugs, splints, or foreign bodies. If possible, the 
cause should be removed and the pain will immediately be 
relieved. When it is not possible to remove the cause, the 
pain may be relieved by applications of ice cloths over the 
nose or applied to the frontal region. Internally, the ad- 
ministration of acetanilide, phenacetin, caffeine, camphor, 
or bromide, either alone or combined, results in relief. 

If headache persists and becomes more severe and con- 
stant, particularly if the eyes become sensitive to light, one 
must bear in mind the possibilities of meningitis develop- 
ing, and immediate measures should be introduced to con- 
trol this serious complication. The combination of head- 
ache, photophobia, and some degree of stupor or mental 
apathy indicates quite clearly the way the case is drifting. 

Nasal Sepsis. — This is much more common than is 
generally supposed. Sepsis occurring after operations may 
be of a severe type or of rather a mild one. It is often 
known as "taking cold," and patients who are supposed to 
have taken cold and developed tonsillitis after operations 
frequently have not taken cold at all, but are suffering from 
septic absorption, expressing itself in inflammation, fol- 
licular tonsillitis, or quinsy sore throat. 

19 



290 



- NOSE AND THROAT NURSING. 



In more serious forms of sepsis one finds pus in the 
region of. the operation, or sloughing, or the extension of 
inflammation into the various accessory cavities of the nose. 

Fortunately these severe cases are extremely rare. 
When a patient has become septic the symptoms are those 
of local inflammation of the nose, headache, pains extend- 
ing into the muscles of the shoulders and down the back, 
chilly sensations which rarely develop into a well-defined 
chill and a feverish condition; sore throat then develops, 
pain on swallowing, local heat and tenderness in the regions 
of the operation, and sometimes slight hemorrhages result 
from the inflammation. 

If the sepsis is mild, the symptoms may subside in the 
course of twenty-four hours. If, on the other hand, it is 
more severe, the case will present evidences of complications 
and will disclose particular symptoms which are dependent 
upon the regions involved. Nearly all cases will develop 
tonsillitis or quinsy sore throat. 

Treatment of Sepsis. — During the operation vomited 
matter may enter the nose and throat, especially if the head 
is hung over the table at the time of operation, and, unless 
cleaned away after the operation, may act as a nidus for 
the beginning of sepsis. As a rule, then, it is well to wash 
over the field of operation — after the operation is completed 
— either with a plain saline solution or a weak solution of 
peroxide of hydrogen, 1 to 40. In minor cases no particular 
attention need be paid to the throat or to the nasal cavities, 
except possibly, in nasal cases, the placing of a plug of 
cotton in each nostril, allowing it to remain for the first 
twenty-four hours after the operation. 

There are certain general rules which may be followed 
regarding the cleansing of the nose after an operation, for 
the prevention of sepsis, which may be used commonly for 



SEPSIS. 



291 



all operations ; but in a few cases it is necessary to make 
particular mention of methods to be employed for special 
operations. 

It is a good rule not to disturb the parts operated on 
for the first twenty-four hours, for during this time nature 
is pouring out an exudate which is purely aseptic and will 
serve fully to protect the wounded tissues for that length of 
time. If no bacteria have been conveyed into the substance 
of the tissue, then after the end of twenty-four hours there 
is no possible danger of sepsis, unless such material be car- 
ried to it subsequently. As a rule, then, a sterile irrigation 
may be given at the end of twenty-four hours, which will 
serve to remove debris, mucus, and blood-clots, together 
with any bacteria which may have entered the nose since the 
time of operation. An argyrol spray (15 per cent.), used 
every three hours, is a satisfactory routine treatment after 
forty-eight hours. 

In operations upon the mouth, except where specially 
mentioned below, it is well, perhaps, to irrigate the mouth 
oftener than has been thought desirable for the nose, be- 
cause it is much more difficult to clean and easily becomes 
infected. It may be best to cleanse the mouth by means of 
irrigation rather than gargling or mouth-washing, because 
these may be the means of carrying infection. The head 
should be tipped well forward, the tongue protruded, and a 
coarse irrigating nozzle placed in the mouth and directed 
against the lateral folds of tissue and the posterior pharynx. 
The same strength of solutions may be used in the mouth as 
in the nose. 

Irrigation of the frontal sinus should always be given 
by the attending physician. After turbinate operations the 
douche should be used to irrigate the nose two or three 
times a day. In case of an operation upon the antrum 



292 NOSE AND THROAT NURSING. 



of Highmore, if the sinus is not padded with gauze, it is 
necessary that it should be irrigated at first every four 
hours and after the second day three times daily. I have 
found a solution of chloride of zinc, about 1 to 10,000, very 
advantageous in irrigating the antrum, of Highmore. 

If the operation for deflection of the nasal septum has 
been done, and packing has been introduced into the nose, 
unless symptoms of sepsis are clearly present, the packing 
should not be removed for forty-eight hours. In case sepsis 
appears, the packing must be removed from the nose, and 
it should be thoroughly cocainized and irrigated. When 
perfectly cleaned the packing may be carefully reintro- 
duced. It may not be necessary again to remove the pack- 
ing for twenty-four hours. 

After adenoid operations the danger from sepsis is 
very slight, because naturally the parts are well adapted for 
self-drainage. Cases of sepsis and one or two cases of 
tubercular infection have been reported, however, showing 
the necessity of aseptic care during an operation and 
aseptic treatment afterward. 

The best way to cleanse the postpharynx after the re- 
moval of the adenoids is by means of a soft rubber catheter, 
the size of which depends on the size of the nostril, one 
being chosen which, when well oiled, will easily pass into 
the postpharynx from the nasal orifice. This catheter is 
attached to a syringe or fountain bag holding a quantity of 
sterile irrigating fluid, and the water is allowed to flow 
gently through the catheter directly into the postpharynx, 
while the head is bent forward and the patient breathes 
through the mouth. In this way the postpharynx can easily 
be cleansed of any discharge without danger of the fluid 
entering the Eustachian tubes or larynx. The fluid returns 
through the opposite side of the nose and is discharged into 



SEPSIS. 



293 



the basin held under the patient's chin. This is a very satis- 
factory method of irrigation of the postpharynx, and may 
be done two or three times a day when there are no symp- 
toms of sepsis. In the event of sepsis occurring, irrigation 
may be employed every three hours. In cases of hemor- 
rhage the douche is contra-indicated, as, in fact, is all dis- 
turbance of the parts, until hemorrhage has ceased. 

Sepsis after adenoid operations is apt to spread into 
the pharynx or to invade the cervical lymphatic glands. 
These glands may suppurate. Such an extreme condition 
is rare. In most cases the limit of sepsis will be an enlarge- 
ment and tenderness of the neck glands. Local applica- 
tions of ice or heat, or soothing applications of chloroform 
or belladonna liniment, applied externally to the neck re- 
lieve the condition rather promptly ; the glandular swelling 
rapidly subsides after septic absorption has ceased. 

After tonsil operations sepsis is of extremely frequent 
occurrence. It is impossible to render the mouth aseptic, 
and infection of the pharynx almost invariably occurs after 
tonsil operation. This expresses itself in pain on swallow- 
ing, tenderness in the glands of the neck, chilly sensations 
or rigors, followed by fever and other classical symptoms of 
sepsis. Much may be done by the nurse to prevent a de- 
velopment of these troublesome difficulties by carefully 
cleansing the mouth with the well-known antiseptic solu- 
tions or anything recommended by the attending physician, 
and by the irrigation of the pharynx from a fountain 
syringe about every third hour. After twenty-four hours 
the danger of sepsis is practically passed, and, unless the 
fibrous exudate which covers over the tonsil region is re- 
moved by instrumental interference, sepsis is not apt to 
occur. 

Occasionally one sees an infiltration of the anterior or 



294 



NOSE AND THROAT NURSING. 



posterior pillars of the fauces. Sometimes this inflamma- 
tion extends downward, attacking the folds of the pharynx 
and sometimes the base of the tongue. Intense pain on 
swallowing is apt to result from this inflammation, which 
may be relieved somewhat by cold applications externally 
or by sucking pieces of cracked ice, or by the application of 
any anesthetic or anodyne solution recommended by the 
physician. Such solutions generally contain certain quan- 
tities of cocaine, eucaine, orthoform, or iodoform, all of 
which are very palliative to this inflamed tissue. The use 
of iodoform or orthoform is particularly useful; the only 
objection to iodoform is its intensely disagreeable odor. Or- 
thoform has almost entirely superseded the use of iodoform, 
and can be recommended to be used in dry form or in emul- 
sion upon these inflamed areas. 

After operations for cleft palate a safe adjunct to the 
treatment is a careful cleansing of the mouth by a sterile 
solution used about every three hours. The nose should 
also be irrigated after operation. The method of doing it is 
most important. It must be accomplished in such a way 
that the patient will not gag, because the movement of gag- 
ging may tear away the stitches and defeat the purpose of 
the operation. All irrigation must be accomplished by the 
patient lying on his face, or rather on his chest, the edge 
of his face being over the edge of the bed. While in this 
position the mouth may be irrigated, using a catheter and 
a stream of water under low pressure or a medicine drop- 
per ; the nose may be irrigated in the ordinary way. 



CHAPTEE IV. 



DIET AFTER OPERATION. 

Diet in Nose and Throat Cases, General Considerations — 
After Laryngotomy and Laryngectomy — Diet in Staphylorrhaphy 
Cases — Diet after Adenoid and Tonsil Operations. — Diet in Ex- 
tirpated Epiglottis — Diet in Intnhatipn. 

In some cases of surgical operation diet plays an im- 
portant role in the ultimate result, and sometimes the issue 
between failure and success is determined by the care which 
the nurse gives to the diet of the patient and the regularity 
with which nourishment is given. 

After surgical operations upon the nose and throat the 
question of diet is always a very important consideration ; 
and the subject at once divides, itself into general considera- 
tions, which apply to all cases, and special considerations, 
after particular operations. As a rule, it may be said, for 
the first twenty-four hours after a patient has had a nasal 
operation, or until the danger of septic inflammation is 
ended, the patient shall be kept more or less on light diet, 
prefeiably of a liquid character. Beef -juice, strong soups 
made of meats, eggs and milk beaten together, and oysters 
are the best to use. Oysters and chopped meat are valu- 
able. After twenty-four hours patients who are allowed out 
of bed may be put on regular diet. In the event of un- 
favorable symptoms developing, particularly fever, it is 
best that patients remain on liquid or semi-liquid diet ad- 
ministered every three hours in quantities of about 6 to 8 
ounces at a time for adults, and for children smaller 
amounts. 

(295) 



296 



NOSE AND THROAT NURSING. 



In most nose operations there are no particular dietary 
instructions ,to be followed except after operations upon the 
antrum through the mouth. In such cases diet is best given 
through a tube, and it should be arranged so that no fluid 
shall enter through the mouth into the antrum or nasal 
cavity. 

Diet in Staphylorrhaphy (Cleft Palate). 

It has been my practice in these cases to feed a patient 
well preceding an operation, giving him a quantity of 
highly stimulating food a safe time before the ether is 
given, and then to starve him for three days afterward, even 
forbidding him water. In certain cases where hunger has 
been so keen that the patient has been unable to go longer 
without food, nutritive enemas have been resorted to. Cer- 
tain quantities of water mixed with peptonized milk, white 
of egg, whisky, sometimes a strong meat-broth, etc., have 
been introduced regularly into the rectum. 

I consider the deprivation of food and water — at least 
the avoidance of its introduction through the mouth — one 
of the very important elements of success in these cases. 
After three days patients may take small quantities of 
liquid nourishment by the mouth with teaspoonful doses of 
water, and no harm will result to the healing. After three 
days more the diet may be increased, but remains liquid in 
character. The incision must be carefully watched and if 
no harm results the diet may be further increased. Soft 
bread, oysters or gruel, or other nutrient articles of the 
same soft consistency may be given to the patient until he 
is taking fair quantities every three hours. Solid food 
must not be given until three or four days after all stitches 
have been removed. 

After tonsil or adenoid operations the comfort of 



DIET. 



297 



the patient is very much increased by the character of the 
diet which is given to him. These patients do not require 
much to eat for the first twenty-four hours, but what is 
given should be of a liquid character. It has been noticed 
that patients who have difficulty in deglutition swallow 
much easier when large mouthfuls are given than when try- 
ing to sip small quantities through a tube. It is therefore a 
good rule that the patient take a large mouthful of liquid 
nourishment ; the pain from swallowing a large mouthful is 
much less than that from swallowing in sips. 

When there is pain after tonsil operations the stumps 
may be rendered less sensitive by the introduction of ice 
preceding the nourishment, or the application of cocaine if 
the pain is extreme. While cocaine may relieve the pain of 
the sufferer, it destroys the desire for food almost abso- 
lutely. A patient is apt to refuse food after cocaine. It is 
better to use ice only. Small quantities may be held in the 
mouth until the tonsils are insensitive. Liquid nourish- 
ment may also be used quite cold. At once we see that ice 
cream is an important adjunct in the nutrition of the pa- 
tient. It consists largely of cream or milk and eggs, diges- 
tible and palatable in cold form. It is readily and easily 
taken by patients, especially by children, when other 
nourishment is refused. It may be necessary occasionally, 
in tonsil or laryngeal operations where the pain of degluti- 
tion is very severe, to pass a catheter through the mouth 
into the esophagus in order to feed the patient. This is re- 
quired only in extreme cases. 

After extirpation of the epiglottis patients experience 
difficulty from food entering the larynx. This is overcome 
by allowing the tongue to sink well back into the mouth 
during the act of swallowing, when it becomes an artificial 
epiglottis, closes over the orifice of the larynx, and forces 



298 



NOSE AND THROAT NURSING. 



food into the esophagus. This method should be practised 
at first with plain water. 

In intubation cases children must be fed while lying 
on the back, while the head is kept lower than the chest 
and abdomen. In this way children are able to swallow 
large quantities of liquid nourishment through a tube. 

Feeding after Laryngotomy and Laryngectomy. 

I. Laryngotomy cases are easier to feed than those 
cases of laryngectomy where the larynx has been removed. 
Where the thyroid cartilage has been incised and subse- 
quently sutured, the case should not receive either water or 
food by mouth for the first twenty-four hours. 

The necessary water may be introduced per rectum by 
Murphy drip method, and if necessary a nutritive enema 
may also be administered. After twenty-four hours the 
swallowing ability should be tested with a teaspoonful of 
sterile water, if successfully accomplished without causing 
spasmodic coughing, e.g., without the water entering the 
larynx, it may be repeated several times and then at regular 
two-hour intervals. Broth and boiled milk may now be 
substituted in quantities of 1 ounce each feeding. The 
patient should be kept on liquid diet until the wounds have 
healed, usually for one week. 

Usually laryngotomy cases are not difficult to feed. 
In cases, where the epiglottis has been removed, however, 
the difficulty with swallowing increases and sometimes 
even the life of the patient is imperiled from continued in- 
ability to swallow. The coughing excited by fluids enter- 
ing the larynx not only discourages the patient from mak- 
ing attempts to swallow but may even tear open the parts 
which have been sutured and annihilate the results ex- 
pected. When this threatens to occur one should feed the 



DIET. 



299 



patient by passing a soft rubber catheter gently into the 
esophagus through the mouth. When it has entered at 
least 12 inches from the teeth, a teaspoonful of sterile water 
may be poured into the funnel attached to its end and if 
coughing does not result then nutrition of a liquid nature 
and water may be introduced in large quantities. Enough 
to satisfy the patient for twelve hours may be given at one 
time and the catheter withdrawn. This procedure is re- 
peated twice daily, each time in exactly the same way until 
the patient is able to swallow. . 

II. In laryngectomy cases the difficulty of feeding is 
much increased. Usually when the operation is completed 
the surgeon passes a very long catheter through the nose 
into the pharynx and then into the esophagus. This tube 
is as large as will pass through the nose and is now left in 
situ, the end projecting from the nose being fastened with 
a silk thread to the cheek by means of a piece of adhesive 
plaster. The patient is then given water and Uquid nour- 
ishment through this tube with the aid of a syringe or fun- 
nel. Much can be said against this method, the secretions 
of the mouth and pharynx are prevented from entering the 
esophagus. Thus they frequently enter the larynx, excite 
coughing attacks, cause the wound to be torn open or to 
become infected from the secretions. The catheter also 
blocks from esophageal swelling or from coagulated milk 
or other debris; or lime salts are deposited about the 
catheter. Such a feeding tube is a source of wound infec- 
tion which should if possible be avoided. 

My own preference is for prolonged rectal feeding 
until the patient is able to swallow, and to use the esopha- 
geal tube only if the nutritive enemata are not retained. 

They should contain peptonized milk, §vj ; sugar of 
milk, oj, and water, gij. They should be introduced warm. 



CHAPTER V. 



SPECIAL THERAPEUTIC MEASURES. 

External Application — Counter-irritants — Splints — Dress- 
ings — Douche: Nasal, Laryngeal, Pharyngeal — Postnasal Douche 
—Application by Spray. Internal Local Application : Solutions 
— Powders — Inhalations — Gargles — Lozenges — Vaccines. 

External Applications. 

In nose and throat work it frequently becomes neces- 
sary to use certain external applications, which may be con- 
sidered under the heads of (1) 'heat and cold, (2) applica- 
tions to produce a soothing effect, (3) applications for 
counter-irritation, and (4) applications for support 
(splints). 

Heat is applied by hot-water bags; by means of a 
sponge wet in hot water and squeezed out; by means of 
a bag of hops or salt heated in an oven to the requisite 
degree of heat; or sometimes a porcelain plate or other 
household articles are used when their form permit their 
application to the regions to which heat is to be applied. 

The most comfortable form, of heat to use about the 
head and throat is either a hot-water bag or a poultice, 
which may be made of flaxseed. 

Cold is best applied to the nose externally by means 
of cloths which have been cooled upon a cake of ice. As 
soon as the cloths are warm a fresh one is applied and the 
other is replaced upon the ice The ice-ca.p, a rubber cap 
filled with small pieces of ice, is often of considerable use 
in nose work, particularly for the relief of headache. If 
used on the throat ice is best applied by means of a bladder 
(300) 



EXTERNAL APPLICATIONS. 



301 



or bag, long and narrow, filled with ice wrapped about the 
throat of the patient. 

Sometimes heat and cold are applied internally by 
means of inhalation, but that will be considered under a 
special head later on. 

Soothing applications are applied to the nose and 
throat generally for the purpose of reducing inflammatory 
swelling, edema, or cellulitis. The class of remedies of 
which lead and opium wash is a type is applied directly 
upon the parts by means of cloths soaked in the solution. 
Other remedies may be used in the same way, as will be 
specially indicated by the attending physician. 

Counter-irritation is generally applied to the larynx 
and sometimes to the nose by means of liniments, or plas- 
ters, or the application of iodine in solutions of various 
strengths. The most common form is tincture of iodine. 
All of these remedies are applied according to the general 
rules laid down in the ordinary text-books on nursing. 

Splints for the support of various parts of the nose or 
throat are applied in cases of fracture, either accidental or 
instrumental. 

The nurse's duty in regard to the management of 
splints is to observe very carefully whether the splint has 
moved from its original position. In case this occurs it 
becomes the duty of the nurse either to notify the physician 
at once or, before his arrival, to make an attempt to replace 
the splint in the position it occupied before it slipped. 

The larynx is seldom supported by means of a splint, 
but sometimes it is necessary to use the splint in fractures 
of the thyroid cartilage. A plaster bandage is generally 
used for such cases. 

Splints for the nose are used externally and internally. 
The external splints are generally held in place by strips 



302 



NOSE AND THROAT NURSING. 



of rubber plaster and a bandage, and often serve the very 
important purpose of holding up the bridge of the nose; 
particularly when cosmetic operations have been performed 
on the nasal bridge to alter its shape. 

These splints, if removed, must be taken away very 
carefully, and, if readjusted, must be done always with the 
idea of making such pressure on the sides of the nose as will 
hold up the nasal bridge. 

The splints which are used inside the nose are placed 
there generally after a fracture of the septum, either from 
traumatism or from an operation done to straighten the 
nasal septum. These splints are generally hollow hard 
rubber tubes and are retained inside the nose by catching 
under the free edge of the nasal orifice. 

Such splints have a tendency to move forward or back- 
ward. They may then be considered ill fitting and others 
should be substituted. If they show a tendency to protrude 
and escape from, the nostril, they may be removed and 
smaller ones used, or more conveniently, held in place by 
means of a narrow strip of rubber plaster placed over the 
end of the splint, turned upward, and fastened on each side 
of the nostril. 

Dressing after Plastic Operations on the Nose 
for Nasal Deformity. 

The dressing to retain the bones of the nose in proper 
position both after fracture of the nasal bones and after 
operations for deformity of the nasal bones as practised in 
the Post-Graduate Hospital, is a very satisfactory one and 
is made as follows : The face and hair after the operation 
are cleaned from blood by gasolene or alcohol, then a strip 
of adhesive plaster 2 inches wide and 2 feet long is applied 
at the middle tightly and firmly to the nape of the neck and 



DOUCHES. 



303 



each end is drawn tightly forward coming under the lobe 
of the ear forward to the cheek on each side as. far forward 
as 1 inch from the side of the nose. This piece forms an 
immovable anchorage for the rest of the plaster which is 
to hold the nose in position. Two tightly rolled gauze pads 
1 or iy 2 inches long and % inch in diameter are placed 
laterally along the base of each nasal bone, one pad on each 
side of the nose. While an assistant compresses the pads 
firmly against the nasal sides a strip of plaster 1 inch wide 
is attached to the anchor plaster on one side, drawn over 
the nose and pads and fastened to the anchor plaster on the 
opposite side. This holds the operated parts firmly under 
the pressure of the pads and plaster. To prevent any slip- 
ping downward of the pads, two and sometimes three pieces 
of plaster are attached to the pads or the strip of plaster ex- 
tending over the nose and then to the forehead. This 
dressing should be renewed each third day until the parts 
are united. 

When transplants of bone are used to relieve "sunken 
nose" deformity the same dressing is used but much more 
loosely applied. 

Nasal, Pharyngeal, and Laryngeal Douche. 

The douche is used for the purpose of removing any 
foreign material, bacteria, scabs, mucus, or pus from the 
nose or throat. 

The douche may also be used to convey a medicated 
fluid for the purpose of the treatment of any of the cavities 
of the respiratory tract; or it may be used for the thera- 
peutic effect of heat or cold. 

The nasal douche may also be used after operations as 
a means of cleansing the parts which have been operated 



304 



NOSE AND THROAT NURSING. 



on, preparing them for the further treatment of the nasal 
surgeon. 

It is possible for some patients to douche the larynx 
so it may be cleaned for the reception of medicines or for 
an operation. The method of using the laryngeal douche 
has already been discussed in a previous chapter. 

PHARYNGEAL DOUCHE. 

The pharyngeal douche is useful for the purpose of 
preparing the field of operation, washing away discharge, 
or for the benefit of direct application of heat and cold. It 
is particularly useful in quinsy sore throat or other forms 
of suppurative diseases of the pharynx. It should be used 
as often as every two hours. The vessel holding the water 
should be 3 or 4 feet higher than the well-flexed head of 
the patient. The communicating tube is generally of rub- 
ber, and the nozzle is of any convenient form that will 
throw a stream into the pharynx. This t is introduced into 
the mouth, the tongue is pressed downward by means of a 
spoon or a tongue depressor, and the liquid is allowed to 
flow freely into the mouth from one side to the other, then 
to the palate, and, last, to the pharyngeal regions. 

If the pharyngeal mucous membrane is douched in this 
way it can be cleansed without the patient having swallowed 
a drop of the liquid. 

NASAL DOUCHE. 

The nasal douche may be given after two methods: 
First, a very coarse atomizer may be used which will throw 
almost a stream of water or very large drops of water which 
almost form a stream. If such an atomizer is used both 
nares will be well cleaned. The second is what is generally 



NASAL DOUCHE. 



305 



known as the "nasal douche," and, while there are different 
methods, that which will be described here has stood the 
test of time and is considered safe and devoid of the usual 
dangers of the nasal douche. It is one that has given entire 
satisfaction in my work : — 

The apparatus to hold the supply of water should have 
a capacity of about 2 quarts, and is best made in the form 
of an irrigating glass or the more convenient form of a 
rubber fountain-bag irrigator. To this reservoir is attached 
a tube which terminates in a perforated .conical-shaped 
tip used to fill the nostril through which the douche is to be 
given. This irrigating bag is filled with water, the tem- 
perature of which is about 110°. In the water dissolve a 
suitable antiseptic, together with a certain quantity of bi- 
carbonate of soda or cHoride of soda, 1 drachm to the 
quart. The bag is hung so that its lower level will be at 
least 4 or 6 inches and not more than 18 inches above the 
flexed head of the patient. In this way a part of the dan- 
ger of the water entering the Eustachian tube is overcome. 
The end of the nozzle is introduced into one side of the 
nostril while the head is bent over and the patient is breath- 
ing through the mouth. If the patient will make no 
attempt to swallow the water when it first flows into the 
naso-pharynx it will immediately make its appearance 
from the opposite nostril, having flowed from one nostril 
into the nasal pharynx, around the nasal septum, and into 
the other side. If great care is taken not to swallow, or to 
breathe through the nose, there is not the slightest danger 
of the liquid entering the Eustachian tube. The douche 
may then be continued on one side until that side is thor- 
oughly cleansed, when the nozzle may be changed to the 
opposite side. This side is washed in the same manner 
as before described, only the flow is in an opposite direc- 

20 



306 



NOSE AND THROAT NURSING. 



tion. If the patient is careful not to blow the nose while it 
is filled with water, but instead will allow the nose to drip, 
there will be no danger of forcing 1 the liquid into the 
Eustachian tubes or any of the accessory cavities of the 
nose. 

It is improper to use the douche when it is hung so 
high that considerable force is obtained by gravitation. 
This is dangerous to the Eustachian tube, and may even 
force the water into some of the accessory sinuses of the 
nose. It is also improper and dangerous for a patient to 
swallow or make any attempt to breathe through the nose 
while the water is running from the douche through the 
nose. An attempt to do this will result either in the water 
entering one or both of the Eustachian tubes or the larynx, 
where it will be expelled by violent paroxysms of coughing, 
which may force the water into the regions where it is both 
harmful and unnecessary. 

It is also improper for the patient to use the nasal 
douche with the head bent backward, and, in fact, to use 
any form of irrigation of the nose by means of the Berming- 
ham douche, or to use any stream of water which may flow 
into the nose while the head is bent backward. By this 
method the water will surely enter the naso-pharynx and 
drop into the pharynx, and in the attempts which the pa- 
tient makes to expel the water from the pharynx it may be 
forced into the Eustachian tubes. 

In resume, then, we may say: — 

1. The nasal douche is better used always after an ap- 
plication of a weak solution of cocaine (1 per cent.), which 
will help shrink the nasal tissues and remove the danger of 
blocking up the water anywhere within the nasal cavity. 

2. Water should be used at a temperature of 110°. 



POSTNASAL SYRINGE. 



307 



3. It must have a specific gravity which will not irri- 
tate the mucous membrane; this is easiest obtained by 
adding 1 drachm of common salt or the same quantity of 
borax or bicarbonate of soda to each quart of water used 
in the douche. 

4. We must remember that the position of the patient 
is important. The head must not bend backward, but be 
flexed so that the chin will nearly touch the chest, and must 
be held over a basin. 

5. The patient must breathe through the mouth during 
the process of irrigation, and not the slightest attempt made 
to draw water through the nostrils. The mouth must be 
wide open during the process of douching. 

6. If it becomes necessary for the patient to cleanse the 
nose by blowing, during the process of irrigation, the flow- 
must be cut off and the nose blown in what may be called 
the open position, — that is, without hand or handkerchief 
being applied to the nostril and with both sides of the nos- 
tril opened, so that the water may drain through both sides 
at the same time. 

7. The nose must be dried by blowing into the hand- 
kerchief only after the excess of water has been allowed to 
run out, or, what is a better method, by the patient breath- 
ing rapidly through the nose six or seven times after water 
has been drained from the nose. 

Postnasal Syringe. 

The postnasal syringe is sometimes used to cleanse the 
nose from behind, and it is claimed for this syringe that, 
as all of the irrigating holes are only on the front of the 
tube, there is no danger of water entering the Eustachian 
tube. The syringe, when filled with the desired solution for 



308 



NOSE AND THROAT NURSING. 



irrigation, is passed into the mouth, behind the uvula and 
soft palate, and is turned upward behind the uvula so 
that the point becomes entirely hidden and the entire curve 
rests behind the soft palate. At the moment this position is 
attained the piston is forced into the barrel and the liquid, 
escaping through the end of the syringe, is injected 
through the nostril and appears at the anterior end of the 
nose. By this method it is possible to irrigate from behind 
forward, through both nostrils, with a rather small quantity 
of irrigating fluid. The head of the patient should be 
flexed forward upon the chest after the nozzle has reached 
its position in the posterior pharynx. 

Sometimes a substitute for the postnasal syringe may 
be arranged as follows: Take the ordinary syringe-bag 
filled with the desired solution for irrigation. A soft 
catheter (generally a No. 6 or No. 12) is well greased and 
is attached to the bag and introduced in one naris for 4 or 
5 inches. In this way the catheter will reach the naso- 
pharynx. The fluid is allowed to escape gently and will 
appear at the anterior nasal orifice, provided the head is 
well bent forward. After one side has been irrigated the 
catheter may be pulled out and introduced into the opposite 
naris. 

It is claimed for this method that the irrigation is as 
thorough as by other methods, and that there is less danger 
of the fluid entering the accessory nasal sinuses and Eusta- 
chian tubes. 

Application by Means of Sprat. 

Application by means of the spray is an easy method 
of medicating the nose, pharynx, and larynx. The ordi- 
nary form of atomizer cannot be termed an entire success, 
since all the forms with which I am familiar get out of 



SPRAYS. 



309 



order very easily. The small covered tube becomes clogged 
and in a short time the usefulness of the spray is ended. 
The better sort to use in the nose is one throwing a coarse 
stream. Into the atomizer bottle may be introduced any 
solution which the physician may direct. The nose is 
sprayed simply by introducing the end of the spray into 
the naris, compressing the bulb a number of times until a 
stream is started, and continuing this for a period of 
fifteen or thirty seconds. It may then be removed and in- 
troduced into the opposite side. 

The pharynx is sprayed by using a straight spray tube ; 
the tongue is depressed by a spoon or tongue depressor. 
The process of spraying the pharynx should not occupy a 
longer time than that of the nose. 

In spraying the larynx it is necessary to use the atom- 
izer with the tip directed downward. This is known as the 
larynx tip. It is more difficult to accomplish the spraying 
of the larynx than of other parts : — 

1. Because it is farther away from the spray. 

2. Because the entrance is blocked by the tongue and 
epiglottis. 

3. Because the patient is apt to tolerate the spraying 
of the larynx less readily than other parts. 

When the larynx is ordered sprayed, the spray tube 
must be introduced while the patient, placing a napkin 
over the end of the tongue, draws the tongue forward by 
means of the thumb and first finger. When the end of the 
nozzle is about % inch from the posterior pharyngeal wall 
and is directed downward, it is in such a position that a 
finely atomized fluid will enter the larynx, particularly if at 
the time of pressing the bulb the patient inhales. 

In the hands of a novice this method of spraying the 



310 



NOSE AND THROAT NURSING. 



larynx is apt to fail. However, after much training a pa- 
tient becomes very expert, and is able himself to use the 
laryngeal spray with success. It is generally better to dis- 
card the laryngeal tip and use some tip for spraying the 
larynx which is recommended for use in the nose and 
pharynx. This does not directly enter the larynx, but the 
atomized liquid fills the pharynx, and, if the patient inhales 
very deeply several times, a part of the atomized fluid will 
enter the larynx. 

It can be said of all forms of sprays that they are gen- 
erally unsatisfactory unless used by the physician. 

Internal Local Application. 

Local applications are made to the region of the nose 
by means of a camel's hair brush or a piece of cotton wound 
on an applicator. 

The best method of applying salve to the interior of 
the nose is by wrapping a match or small stick or a metal 
applicator with a wad of absorbent cotton and then dipping 
this improvised brush into the salve until it is covered with 
a thick layer of salve. This is introduced into one nostril, 
both of which are grasped with fingers so as to compress the 
nasal wings upon the cotton. The match is drawn forward, 
bringing the cotton with it, but leaving the salve. The 
ointment is easily sniffed backward into the more posterior 
regions and into the naso-pharynx. 

The pharynx is treated with local applications applied 
by means of a swab. It is generally larger than the nasal 
applicator, with cotton wound into a rather large brushlike 
end. This is dipped into a medicament, which is swabbed 
directly over the pharynx after the tongue is depressed. 

To introduce the applicator into the posterior pharynx, 



INTERNAL LOCAL APPLICATION. 



311 



it is necessary that it should be bent forward at an angle of 
nearly 90 degrees; this end may be carried into the naso- 
pharynx behind the uvula and soft palate and an applica- 
tion made directly to the pharyngeal vault. 

Local applications to the larynx are made by means of 
the laryngeal brush or the laryngeal applicator. If the ap- 
plicator contains an arrangement by which the cotton may 
be wound so that it cannot loosen in the larynx, it is a per- 
fectly safe instrument. But if the ordinary laryngeal appli- 
cator is used, it is necessary that the cotton should be more 
firmly twisted on the end of the applicator. It is dangerous 
to use in the interior of the larynx an applicator covered 
with cotton where the cotton is not firmly secured, because 
•the moment the cotton is received between the borders of 
the vocal cords they close violently on the object and may 
free it from the applicator. The cotton is then inspired 
and is often the cause of septic pneumonia and abscess of 
the lung. If the loosened cotton is not inspired it may re- 
main in the larynx and cause considerable trouble from 
irritation or it may cause suffocation. 

In order to properly wind the cotton, the fibers should 
ail be long, should lie parallel, and the layer of cotton 
should be rather thin. This thin layer of cotton with 
parallel fibers is then received on the roughened end of the 
applicator which has been moistened in a watery solution. 
When the end of the applicator has been wet, it provides 
a very firm attachment for the fibers of cotton which lie 
next to the applicator, and they will be fastened so firmly 
that they cannot be dislodged or removed. The cotton 
must be wound so as to cover about 1 inch of the end of the 
applicator. If wound too near the end of the applicator it 
may loosen. 



312 



NOSE AND THROAT NURSING. 



POWDERS. 

Powders of various kinds are sometimes used in the 
nose, pharynx, and larynx, when they are applied by means 
of the ordinary powder blower. 

It is not necessary to describe these blowers. The pow- 
der is either received into a small cylinder which is a part 
of the powder blower and is used when small quantities of 
powder are required, or the powder is placed in a reservoir, 
which is generally a bottle. When introduced into the nose 
or pharynx care must be taken to instruct the patient to 
exhale rather than to inhale; otherwise the powder will 
enter the larynx and produce severe coughing and conse- 
quent irritation. 

Vapor or Steam Inhalations. 

The use of heated moisture as a method of conveying 
medicaments into the respiratory tract was formerly used 
much more than now, but is still useful in certain classes 
of cases, particularly for croup in children, and also in some 
cases of laryngitis. The ordinary method of using steam 
inhalations is to fill a vessel, having a properly arranged 
mouthpiece for inhalation, with boiling hot water and in- 
troduce into this boiling water a certain quantity of an 
ordered medicament. The steam arising from the water 
carries with it a small quantity of medication and the 
steam is inhaled by the patient as long as necessary. The 
ordinary inhalers sold in drug stores are known as Maw or 
the benzoinal inhaler. The latter has the advantage of 
simplicity, economy, and durability, and can be placed di- 
rectly upon a gas stove. The Maw cools so quickly that it is 
practically of no use, and the inhalation tube is so short 
that the inhaler cannot be used on a gas stove. 



INHALATIONS. 



313 



An improvised inhaler may be made at any time by 
taking an ordinary porcelain pitcher, fitting over the top 
a cornucopia made of rather stiff oiled paper, the large end 
of which may be introduced into the open end of the pitcher 
and the small end into the mouth. Hot water and medica- 
tion are added and inhaled for from three to five minutes. 

Different medicaments are used for inhalations, gen- 
erally volatile oils or ethereal tinctures. 

Steam atomizers have been in use, but are not much 
used at present; although they work better than inbalers, 
they are expensive and easily get out of order. They are 
apt to make the throat more tender and thus necessitate the 
patient's remaining in the house after their use. 

The boiler form of steam atomizer is the most con- 
venient form to use for the purpose. It consists of a small 
boiler placed over a spirit lamp, discharging steam from a 
spray tube at one end, while the other end of the spray tube 
is placed in the medicament desired. The atomized steam 
by suction carries the medicament through the spray tube 
and atomizes it at one end, throwing it forward to the 
breathing receptacle and into the patient's mouth. 

Essential oils, turpentines, and various antiseptics, 
soluble in water may be used in this form of inhaler. 

Burning inhalations are principally used in affections 
of the lungs and especially in asthmatic conditions. They 
are inhaled by the patient under a shawl ; the powder, hav- 
ing been touched with a match, burns slowly, emitting a 
medicated smoke. The best of all inhaling powders is 
nitrate of potash, to which is added the medicament ac- 
cording to the requirements of the case. Favorite remedies 
are black tea, camphor, benzoin, sandal, hyoscyamus, and 
lobelia. 

Inhalation by means of the oily spray nebulizer is by 



314 



NOSE AND THROAT NURSING. 



far the best way of introducing medication in an atomized 
form into the bronchial tubes, larynx, or nose. Inhalations 
by means of the oily spray are made the same as those de- 
scribed under the head of "Sprays." 

Gargles. 

Gargles are an antique method of medicating the 
throat, and as used today they are found to be of practically 
no value whatever, except as washes for the mouth or the 
anterior surface of the tonsils, the fauces, and the soft 
palate. 

Experiments have been made on patients who have 
been ordered to gargle various solutions colored with aniline 
dyes, which have the property of staining the interior of the 
throat. After gargling examination was made and the 
parts reached by the gargle and discolored by the aniline 
dyes were the base of the tongue, the soft palate, the ante- 
rior surface of the tonsil and the anterior pillar of the 
fauces. It can be seen, then, that these are useless for 
cleansing the pharynx, and are in every way inferior to the 
method described under "Douching of the Pharynx." 

Gargles are useless in adults and impossible in chil- 
dren, while irrigation of the pharynx is easily accomplished 
in the most timid children. When the gargle is ordered, 
it is almost always used diluted with water. The patient 
should throw the head well back, fill the mouth with the 
solution, without making the usual vigorous attempts to 
circulate the liquid in the mouth. The medicament should 
be allowed to run slowly back as far as it will into the 
pharynx. After holding the solution in this manner for a 
few seconds, it is discharged by spitting. The mouth is re- 
filled, and the process repeated until the ordinary quantity 
of gargle has been used. It is generally necessary that at 



VACCINES. 



315 



least a half-cupful (4 ounces) of water should be used 
each time the gargle is ordered. 

Lozenges. 

Lozenges are not much used for the treatment of 
throat conditions, but occasionally are ordered for the pur- 
pose of moistening the throat. They produce secretion of 
mucus and saliva. There are various lozenges recommended 
for this ; the list is a long one. The method of use is the 
same for all : the lozenge is held upon the tongue, or 
tucked between the tongue and the teeth, where it slowly 
dissolves, and, if it contains any medication, this is slowly 
swallowed with the saliva, in the hope that it may be of 
some therapeutic value. 

Lozenges are a comfortable accessory to the treatment 
of throat conditions, particularly in singers and speakers 
who are troubled with a dryness of the throat. 

Vaccines. 

The use of bacterial vaccines is common in the treat- 
ment of nose and throat infections. The method of ad- 
ministration is like any hypodermic medication. The dose 
of vaccine is specified by the attending physician. The 
nurse must be on the alert for symptoms of "reaction," 
fever, chilliness, rigor, headache, malaise, pains in extremi- 
ties, sometimes nausea or vomiting. Eeaction should result 
from the use of vaccines, but should usually not be pro- 
longed more than twelve hours. For other details see page 
117, Eye Section. 



CHAPTER VI. 



NURSING METHODS IN PARTICULAR CASES. 

Diseases of the Nose. 

External diseases of the nose, such as acne, furuncle, 
verruca, sebaceous cysts, nevus, syphilitic ulcerations, lupus, 
and rhinoscleroma, deserve but little mention at our hands, 
for there is little connected with them that pertains to the 
duties of a nurse other than the application of ointments 
or medicinal preparations and surgical measures which re- 
quire no special training of the nurse. In the destruction 
of nevus, however, it may be mentioned that, when elec- 
tricity has been used, sometimes an unpleasant cellulitis or 
reaction will follow the use of the electric needle, whether 
for chemical disintegration or as a caustic. Under such 
circumstances the nurse should make applications to the 
inflamed area as soon as this is noticed. The advent of 
cellulitis is shown by the presence of slight fever, redness, 
and swelling. Ice may be applied at once, or, what is still 
better, cold applications of a saturated solution of aceto- 
tartrate of aluminum. The lotio plumbi et opii is also a 
favorite application in these cases. 

Fracture of the nose, whether done artificially for 
cosmetic operation on the nose or as a result of traumatism, 
may be treated by the nurse in the same way. It is further 
the duty of the nurse to observe the position of the band- 
ages, to see if all dressings are in place, and that the splints 
which are used for the support of the septum have retained 
their original position. It is the tendency of all nasal splints 
when applied externally to move downward on the face. 
(316) 



DIPHTHERIA. 



317 



They seem to be drawn down by the muscular movements of 
the face. In case of dislocation of the bandage producing 
any deformity in the freshly broken nose, the parts should 
be gently pressed into place again and the splints applied 
temporarily until the surgeon arrives. 

Internal Diseases of the Nose. 

acute rhinitis. 

In acute rhinitis or cold there is not much for a nurse 
to do, and few people who take, cold have a nurse to attend 
them. However, a nurse's duty in such cases is to maintain 
an even temperature of the room, between 72° and 76° F., 
to keep the patient in bed and to use massage. The diet 
should be of a liquid character until otherwise ordered, and 
the medicine should be given with great regularity. It is 
rarely necessary in most people to treat the early stages of 
a cold actively, but, with public speakers, singers, and 
actors, it is highly important that a cold should be checked 
at the earliest possible moment. It is in these cases that a 
nurse may be required to aid in a rapid convalescence. 

DIPHTHERIA. 

Perhaps there is no other disease in the catalogue of 
nose and throat diseases in which the duties of a nurse are 
so exacting, persistent, and important as are those which 
we are now to discuss. Not only do her duties relate to 
her patient, but they extend also to herself, and to the pro- 
tection of others both during the disease and afterward. 

Her first duty is, of course, to her patient, and isola- 
tion is the first of all. A patient with diphtheria must be 
isolated, and this must be more than practical ; it must be 



318 



NOSE AND THROAT NURSING. 



absolute. The isolation must extend in a certain measure 
to all the people in the house, and care should be taken to 
prevent the spreading of the contagion. The expectoration 
or secretions from the patient must be received in an anti- 
septic solution. The best for the purpose is a solution of 
carbolic acid, 1 to 40, or, what is even better, because it has 
no odor and is more aseptic, a solution of bichloride of 
mercury, 1 to 1000. 

All the receptacles which receive the expectoration or 
secretions from diphtheria patients must contain a quan- 
tity of one of these antiseptic solutions, and the outside 
parts of such receptacle must also be moistened with the 
antiseptic solution, since this part as well as the reservoir 
part may become germ infected. 

Tieces of old linen or antiseptic gauze are to be given 
to the patient instead of handkerchiefs or towels, and these 
should be immediately burned after using. 

Such bedding and clothing as are apt to be soiled by 
expectoration or secretion containing diphtheria germs 
must be placed in a carbolic solution of 1 to 40 and after- 
ward boiled, or put in a solution of sulphate of zinc, 1 
drachm to a quart, previous to boiling. It is a good rule 
for all bedding and clothing which have been used about a 
patient to be dampened with this antiseptic solution before 
they are taken from the sickroom. 

The eating utensils which have been used in the sick- 
room must be put in an antiseptic solution and cleaned be- 
fore they are returned to the kitchen. The best solution is 
a zinc salt solution, particularly sulphate of zinc, 1 drachm 
to a quart ; after being dipped in this solution the utensils 
should be boiled. After washing they must be boiled again 
before they are used. 

The nurse should have ready at each of the visits of the 



DIPHTHERIA. 



319 



physician, a gown which will be sufficient to cover the 
visitor from his collar to his feet, and which may be used by 
him during the visit in the sickroom. This seems to be an 
unnecessary detail in some mild cases, and yet there is 
always the possibility that a shred of membrane may remain 
in his clothing where it has lodged when the patient ex- 
pectorates or gags and may act as a carrier of infection 
to the next case he visits. Besides this, after visiting a 
diphtheritic case the physician should disinfect his hands 
and face, washing them with soap and water and afterward 
with a bichloride solution 1 to 1000 for the face and 1 to 
500 for the hands. 

In order to protect the physician from personal con- 
tagion and the development of diphtheria in his own per- 
son, it is always necessary for him to wash out his mouth 
and gargle his throat with a weak solution (1 to 5000) of 
the above, or, if this is not desirable, with some sterile 
saline solution. 

In case the nose or throat of the nurse becomes in- 
fected by expectorated membrane while caring for a pa- 
tient, that part where the infected material has touched 
should be cauterized at once with any caustic which may 
be on hand, and afterward the mucous membrane should be 
washed very thoroughly by means of a douche. 

Every precaution should be taken to protect both the 
physician and the nurse from an attack. The nurse should 
also protect herself against the dangers which lie in the 
constant dropping of discharge from the nose and mouth 
of the patient on the bedclothes and nightdress. 

The hands of the nurse must be frequently washed 
with a disinfectant, consisting of bichloride, 1 to 1000, or 
carbolic acid, 1 to 80. For this purpose a large bowl of 
this solution should be kept in the sickroom, where the 



320 



NOSE AND THROAT NURSING. 



nurse can bathe her hands often. In addition to disinfect- 
ing her hands the nurse should cleanse her mucous mem- 
branes by washing them either with a solution made by 
dissolving a Seiler tablet in a glass of water or by spraying 
the nose and throat with a Dobell solution. After this has 
been done the mucous membranes may be thoroughly 
washed with a sterilized saline solution. 

The nurse, in addition to these precautions, must also 
receive from the physician, before taking care of a case of 
diphtheria, an injection of antitoxin, in order to immunize 
her. This injection should be given before the nurse enters 
upon her duties. Five thousand units of antitoxin are gen- 
erally enough. 

The nurse's duty in diphtheria includes also the pro- 
tection of other individuals in the household besides her 
patient ; and it becomes a part of her duty to see that care 
is taken that no spread of the diphtheria results from care- 
lessness on her part by allowing the friends to come in con- 
tact with the patient. It may not be generally known to 
the nurse, but it is a well-established fact, that, even when 
cases of diphtheria are apparently well, there is still danger 
of their infecting other individuals. 

To establish this fact cultures from the throat have 
been made in nearly two thousand cases of diphtheria 
which had entirely convalesced so that there was no evi- 
dence of diphtheritic membrane, and yet in a large propor- 
tion the presence of the diphtheritic bacillus was demon- 
strated in the mouth and nose of these patients after they 
were apparently well. In most cases the diphtheritic bacil- 
lus was found until two weeks after the patient had been 
entirely rid of the membrane; in some cases it persisted 
as long as four weeks ; at the longest, ninety-one days. 

After a case is well enough to be removed to another 



DIPHTHERIA. 



321 



room, the nurse may be requested to properly disinfect the 
sickroom. In cities this is generally looked after by the 
Board of Health, but in the country this duty sometimes 
falls to the nurse. 

The room in which the patient has been confined must 
be thoroughly cleaned. The walls must be scrubbed down 
with wet fresh bread, cut in pieces large enough to hold 
in the hand, and the entire wall rubbed downward until 
every inch of surface of paper or paint has been gone over 
with this damp bread. It is surprising what a quantity of 
dust and other material will be removed by this method 
and with it comes any of the germs which may have lodged 
on the paper or walls. If the walls are painted they may 
be washed with soap and water. Carpets and upholstery 
must be removed from the room and subjected to a clean- 
ing by steam. After the carpets have been taken up the 
floors must be scrubbed thoroughly with soap and water, 
having first been sprinkled with a bichloride solution of 
1 to 1000. The clothing and all linen and white cloth 
which has come in contact with the patient must be boiled, 
while books and toys must be destroyed. It is always 
wisest to destroy books and toys, particularly as the toys 
may have come in direct contact with the mouth of the 
patient and may be a very virulent agent in spreading the 
disease. Books, if valuable, however, need not be destroyed, 
but may be disinfected by means of formaline gas. 

It further becomes the nurse's duty to report to the 
attending physician any invasion of the quarantine by out- 
siders. It is better that the nurse should frankly notify the 
attending physician in case the quarantine rules are broken, 
so that the physician may give to the person who has broken 
through quarantine an immunizing injection of antitoxin. 
Five thousand units are generally sufficient. 

21 



322 



NOSE AND THROAT NURSING. 



In the treatment of diphtheritic eases it ia a duty of 
the nurse to see that the rooms are properly ventilated and 
lighted. The air of the room should be constantly changed 
and the temperature should not be allowed to get below 66° 
or higher than 72° unless specially ordered by the physi- 
cian. During the sunny portion of the day the shades 
should be raised and the sunlight allowed to stream into the 
room as long as possible; nothing is so potent a destroyer of 
contagion as sunlight. 

In all cases, unless otherwise ordered, from the incep- 
tion of the disease the patient should be kept on a liquid 
diet; nourishment should be given every three hours. The 
patient must neither get out of bed or make any exertion, 
nor must he attend the toilet. This rule is imperative not 
only during the course of the diphtheria, but must be more 
particularly and carefully enforced after convalescence has 
been established, for it is at this time that diphtheritic cases 
exhibit sudden attacks of heart paralysis, and sometimes 
during convalescence fall over dead from exertion. 

'Many physicians use the croup kettle in diphtheritic 
cases. It moistens the atmosphere in the room, and in- 
creases the water on the respiratory mucous membrane. It 
is used both night and day, and at certain regular intervals 
is placed over the bed in which the patient is lying. The 
steam from the croup kettle is sometimes medicated. If 
this is desired various essential oils, turpentines, and other 
remedies are used: carbolic acid, turpentine, benzoin, oil 
of pine needles, creosote, and lime-water are added to the 
boiling water. The croup kettle, however, must be used 
only by the direction of the attending physician. In an 
emergenc) 7 , a very satisfactory croup kettle may be con- 
structed from an ordinary tin teakettle placed on a gas 
stove. The spout of this kettle may be elongated by the 



DIPHTHERIA. 



323 



addition of a bit of tubing or metal pipe This kettle is 
to be placed at a convenient distance from the patient 
where the heat will not be too great, and the steam is de- 
livered from the elongated spout, the end of which should 
be fixed near the patient's head. 

Local Treatment of Diphtheria. 

In the local treatment of diphtheria the duties of the 
nurse are more or less limited. She will probably be 
ordered to cleanse the infected area of the membranous 
debris, and for this purpose the physician will order a hot 
normal saline solution, which is about a 0.8 per cent, solu- 
tion, or, in round quantities, 1 drachm of salt to the pint of 
water. Sometimes a boracic acid solution is substituted for 
this, or peroxide of hydrogen may be used as a spray or a 
wash. If peroxide of hydrogen is ordered, it should not be 
used stronger than 10 per cent, and seldom stronger than a 
1 per cent, solution. It is necessary for the nurse to notice 
whether the use of peroxide of hydrogen produces pain, 
and, if it does, to discontinue the remedy. A poultice of 
flaxseed or a hot-water bag is ordered by some physicians, 
and cold by means of the ice-cap or icebag by others. 

General Treatment. — The general treatment of 
diphtheria consists in the regular administration of the 
medicines and the use of calomel fumigations. These 
fumigations are the favorite method of treatment in the 
hands of some specialists, and seem to be particularly use- 
ful in the cases of young children. 

Calomel Fumigation. — The patient is laid upon blank- 
ets on a table, to the sides of which have been nailed some 
half-hoops in such a way as to form a series of arches over 
the patient. These should arch a couple of feet above the 
top of the table. A cloth is laid over the arches in such a 



324 



NOSE AND THROAT NURSING. 



way as completely to close the space over the table on the 
sides, top, and ends, except at one end of the table, where 
the cover extends some distance from the end of the table, 
so as to leave a space between the foot of the table and the 
end of the covering. Under this is placed an alcohol lamp, 
and over this lamp a platter or metal pan upon which 15 
grains of calomel are to be sublimed. The alcohol lamp is 
lighted to heat the calomel and the vapors, rise from the 
free end of the arch, and are inhaled by the patient who is 
beneath. This fumigation should be carried on for fifteen 
minutes. The length of time is always about fifteen min- 
utes, but the frequency varies with the date of the disease. 
It is a convenient rule to say that 15 grains should be sub- 
limed every two hours on the first and second days, every 
three hours on the third day, every four hours on the fourth 
day, and after that only three times each day. 

Intubation. — In cases where intubation is required, the 
duties of the nurse are very important. During intubation 
it will be her duty to hold the patient quietly during the 
operation, but her duties afterward are even more impor- 
tant. To prepare a patient for intubation, the child should 
be completely wrapped with a sheet from the neck to the 
legs, and the sheet should be tightly pinned behind, while 
the arms and legs are straight, so there can be no voluntary 
movements of the hands or legs to interfere with the opera- 
tion. Care must be taken in pinning the sheet behind not 
to make it so tight that the patient who has difficulty in 
breathing will be in any way hampered for breath by un- 
usual constriction of the chest. The nurse should then sit 
with the patient in her lap, the limbs of the nurse being 
spread apart and the legs of the child received between her 
knees, while the legs of the nurse are crossed in front of 
the legs of the patient so as to hold the patient' s legs firmly 



DIPHTHERIA. 



325 



from kicking forward or jerking upward. The shoulders 
and head are held by the nurse by placing the palm of each 
hand firmly on the side of each ear and allowing the elbows 
to drop over the shoulders of the patient. In this position 
the nurse lias absolute control over the feet, shoulders, and 
head of the child, while the hands are firmly confined in 
the pinned sheet, and any movement which would inter- 
fere with the operation is prevented. The child's head 
should be held absolutely horizontal. 

During the operation the nurse has no other duties 
than that of holding the child immovable; but after the 
operation it becomes her important duty to watch the string 
to which the intubation tube is attached, if this be not cut 
and removed, to watch the breathing of the child, to see 
that the tube is kept clear from mucus, and to attend to the 
feeding of the patient at regular intervals. 

After it has been ascertained that the tube is in the 
larynx, and the difficulty of breathing has been relieved, it 
is common in this country to cut the string which is at- 
tached to the tube and withdraw it. Abroad it is some- 
times customary to allow the string to remain in place. 
Then it is drawn through the mouth alongside of the cheek 
and is loosely tied around the ear. As the string is very 
macli in the way, there is a constant danger that the child 
may dislodge the intubation tube by pulling the string. 

The only purpose which a string can serve after the 
tube is in the larynx is for the quick recovery of the tube 
in case it should be expelled. If the string is removed, it 
becomes the nurse's duty to carefully watch for the tube, 
and if there are any indications that the tube has become 
dislodged the patient must at once be turned head down- 
ward and the fingers introduced in the pharynx to grasp 
the loosened tube before it can be swallowed. 



326 



NOSE AND THROAT NURSING. 



Another duty of the nurse after an operation is to 
see that the tube is free from mucus. The patient gener- 
ally attends to this fairly well, for, when the tube is clogged 
with mucus, the patient attempts by violent expiration to 
dislodge it. If he does not succeed and there seems to be 
some permanent obstruction of soft tissue or mucus in the 
tube, the nurse should allow the patient to swallow a small 
quantity of water, when the mucus or shreds of necrotic 
tissue will be expelled by violent coughing. It rarely be- 
comes necessary for the nurse to remove the tube. If, how- 
ever, the patient becomes cyanosed from an obstruction of 
the tube which seems to be permanent, and it becomes im- 
perative that the tube should be taken out, it may be re- 
moved by the nurse by pressure on the trachea below the 
level of the tube, stripping the trachea and larynx from 
below upward, while the patient is placed with the head 
downward. In this way it will become possible often- 
times to remove the intubation tube if it is desired to do 
so in an emergency. 

The feeding of infants who are wearing intubation 
tubes is accomplished by placing the patient on the back or 
side with the head lower than the feet, all the swallowing 
to take place while he is in this position. In this way it be- 
comes possible for intubation patients to take quantities of 
nourishment without any entering the larynx through the 
intubation tube, while, if the patient is fed in a sitting posi- 
tion, it becomes almost impossible to take any kind of 
nourishment because of food entering the trachea through 
the tube. 

AY hen it becomes necessary to remove the tube from a 
young child, it is always wise for the nurse to prepare the 
patient as previously described for the introduction of the 
tube; and after the tube has been removed to keep down 



DIPHTHERIA. 



327 



the tendency to swelling and edema by means of the appli- 
cation of an icebag to the throat. 

Antitoxin. — When antitoxin is to be used, the nurse 
must prepare the skin between the shoulders and under one 




Fig. 32. — Stripping the Trachea, and Larynx to Remove 
Clots of Blood or the Intubation Tube. 



shoulder blade by washing it with soap and water generally. 
It should be washed afterward with a carbolic solution or 
rubbed with alcohol ; and thus the skin is rendered fit for 
the introduction of the antitoxin hypodermic needle. The 



328 



NOSE AND THROAT NURSING. 



absorption of the antitoxin is accelerated by gentle massage 
of the part. A bit of plaster may be placed over the punc- 
ture to prevent infection. Unfavorable symptoms from 
antitoxin are rarely seen, but sometimes an eruption of the 
skin similar to scarlet fever follows the use of this remedy. 

HYPERTROPHIC RHINITIS. 

Cases of hypertrophic rhinitis generally require the 
nurse only during and for a few days after the operation. 
The nurse's duties in these cases are of such a general 
nature as have already been described while discussing local 
applications, cocainization, douches, preparations of the pa- 
tient, cauterization, care of instruments, etc. 

Sometimes the physician in the office treatment of 
these cases uses a galvanocautery instead of using medicinal 
cauterizants. In case medicinal cauterizants are used, it 
may be well for the nurse to be familiar with their method 
of application. Generally either chromic acid, mono- 
chloracetic acid, or silver ntirate is used. All of these are 
best applied by means of heating a metal applicator and 
dipping it in the remedy to be used, so that a small globule 
of the melted material will adhere to the withdrawn probe. 
By gently heating this over the flame it can be made to run 
down to the very end of the probe, forming, when cool, a 
solid little ball, which may be used in this form. 

OPERATIONS ON THE ACCESSORY NASAL SINUSES. 

In diseases of the antrum of Highmore nearly all that 
has been said about the conduction of cases along ordinary 
lines of surgical procedure, irrigations, and the use of pow- 
ders applies to these cases. The ice-cap or cold or iced 
cloths applied to the cheek or eye are useful to keep down 



TONSIL OPERATION. 



329 



swelling, ecchymosis, or pain after these operations. In 
frontal sinus cases all that has been previously said about 
general surgical procedure, douching, and irrigation will 
also apply to the cases. But particular attention must be 
paid in case the skin incision has been closed that the irri- 
gation of the frontal sinus is not carried on in such a way 
as to produce pressure on the sutures. After operations 
upon the ethmoidal cells the nurse's duties include the em- 
ployment of external applications and irrigation; but in 
these cases the nurse must watch the eye and the lid for 
evidences of congestion, inflammation, or ecchymosis. 

Quite frequently from sixteen to twenty-four hours 
after these cells have been opened, there will be some ecchy- 
mosis of the upper lid. This may not be of any importance, 
but as soon as it appears iced cloths should be applied to 
the eye and to the nasal region. Emphysema of the upper 
eyelid in these ethmoidal cases indicates perforation of the 
orbital plate. Iced cloths are the proper remedies. 

Tonsil Operation. 

After the tonsil operation the nurse's duties are of the 
highest importance. She may detect the beginning of a 
hemorrhage which, if prolonged, may be serious and she 
may add greatly to the comfort of adult patients, who, to 
say the least, are usually decidedly uncomfortable after the 
operation. 

If the operation has been performed under local anes- 
thesia these duties are simplified into watching for an 
easily detected hemorrhage manifested by the conscious 
patient expectorating bright red blood, but when the opera- 
tion has been performed under general anesthesia and the 
patient remains unconscious for an extended period an ex- 



330 



NOSE AND THROAT NURSING. 



tensive, even dangerous, hemorrhage may occur unless the 
nurse is alert to detect it. 

All unconscious patients after the tonsil as well as 
after the adenoid operation should always be kept on the 
abdomen or the side with the head low. In this position if 
bleeding occurs the blood will flow from the mouth or nose 
and will be detected at once. In any other position the 
blood will trickle down the throat, will be swallowed and 
this hemorrhage may go on undetected until the patient is 
exsanguinated and exhausted. * 

Suddenly such a patient will show a very rapid and 
feeble pulse, this will be followed by the vomiting of a large 
quantity of blackish discolored blood. If further neglected 
the patient will continue to bleed and death may result. 
How important then is it for the nurse to keep her patient 
on the abdomen or side with head low rather than to run 
such a risk ! Semi-unconscious cases partially recovered 
from their anesthesia are not easy to keep in this position, 
and try the patience of any nurse. But we all know that 
good nurses are endowed with exhaustless patience and are 
ready to replace again and again the restless and un- 
reasonable client. I know of no other method of detecting 
bleeding with the patient on the back except to watch the 
case for regular swallowing. This indicates that blood is 
being swallowed but it is not safe to rely upon it. 

The vomiting of a quantity of dark blood once is not 
a symptom of any importance unless the pulse becomes 
rapid and feeble afterward. The repeated vomiting of dark 
blood in which some bright red streaks may be discerned is 
a symptom of great importance and warrants notification of 
the surgeon at once. 

After recovery from ibe anesthesia the danger of 
hemorrhage is practically ended and children, especially, 



TONSIL OPERATION. 



331 



have very little pain or discomfort. Adults, however, suffer 
more pain and discomfort than children and may require 
the application of icebags to the outside of the neck and 
sometimes we allow them to suck pieces of ice. As a rule, 
however, it is better to keep the patient from swallowing. 
One should also not use any spray or gargle for the first 
forty-eight hours but should be satisfied to apply icebags if 
necessary and limit the swallowing to liquid food or ice 
cream in small quantities infrequently repeated. In adults, 
sometimes, a dose of morphine sulphate, % grain, is ad- 
visable the first night. 

After two days the physician may order a spray of 
argyrol 10 to 20 per cent, used each four hours. The 
throat should not be sprayed before this, nor should any 
attempt be made to dislodge or remove the white membrane 
which in all cases covers the operated field after the first 
twelve hours. 

Adults infrequently complain of great discomfort 
from swallowing even later than forty-eight hours after the 
operation. In such cases it is advisable to use an anodyne 
powder and they experience great relief if the throat is 
covered each three hours with a powder blown upon the 
operated parts by a powder blower. Such an anesthetic 
powder is compounded of equal parts of orthoform, ace- 
tanilide, and gum acacia. 

Gargles, solid food, talking, all increase the muscular 
movements in the throat, therefore increase pain. They are 
inadvisable. The patients until all difficulty with swallow- 
ing disappears, should limit their efforts to swallowing 
liquid or semi-solid foods: milk, eggs, cocoa, ice cream, 
oysters, soft, well cooked cereals, milk toast, custard. After 
twenty-four hours adults may be allowed out of bed and 
next day may be allowed to go out of doors. 



332 



NOSE AND THROAT NURSING. 



PERITONSILLITIS (QUINSY SORB THROAT). 

The nurse may be required to irrigate through the in- 
cision which has been made into the pillar of the fauces. 
The small nozzle is atached to the syringe or fountain bag, 
containing a proper antiseptic solution, and introduced into 
the wound, the patient's head being bent forward. The 
irrigation is performed under low pressure. 

EDEMA OF THE LARYNX. 

In cases of edema of the larynx it is necessary for the 
nurse to apply ice to the neck and to give the patient ice 
in small pieces to suck. Careful attention must also be paid 
to the degree of difficulty in breathing, and upon the slight- 
est increase of this difficulty the physician must be notified 
at once. Sometimes it is possible for a nurse to save the 
life of a patient by using a good-sized soft rubber catheter 
as an intubation tube. It is passed over the epiglottis and 
base of the tongue into the larynx, and beyond the area of 
the edema. This tube may be left in place indefinitely, but 
it should be tied to one ear by means of a string. 

TUBERCULOSIS OF THE LARYNX. 

In cases of tuberculosis of the larynx the greatest dan- 
ger is the development of edema, in which case the nurse 
should follow the lines indicated under the head of "Edema 
of the Larynx." Edema is particularly apt to develop in 
cases which have been curetted or where the tubercular areas 
have been excised. 

TUMORS OF THE LARYNX. 

Cases of tumors of the larynx may require tracheot- 
omy. In such cases all that has been said about the care of 



OPERATIONS ON THE LARYNX. 333 



the patient during tracheotomy applies to these cases. If 
the cases have been operated on from the inside (endo- 
laryngeal) the remarks which have been made concerning 
edema of the larynx are applicable. If, in order to reach 
the tumor, the larynx has been split and sutured (fissure 
of the larynx), the remarks which have been made concern- 
ing edema of the larynx and acute inflammation of the 
larynx are applicable. 

In cases where the larynx has been excised the case 
must be treated along the lines of general surgical proced- 
ure, and particular attention must be paid to hemorrhage 
and the danger of inspiring blood or mucus. (See also 
page 297.) 

OPERATIONS ON THE LARYNX. 

I. Internal Operations on the Larynx. — After purely 
internal operations upon the larynx the patient should ab- 
stain from using the voice except as a whisper for two or 
three days. If inhalations of steam are ordered they 
should be used as mentioned on page 312. The usual treat- 
ment is to spray the larynx with an argyrol solution 10 or 
20 per cent., about each three hours (see page 309), per- 
haps to follow this spray with one of an oily character, and 
to attend most punctiliously to the hygiene of the mouth 
and teeth. 

IT. In External Operations on the Larynx. — Laryn- 
gotomy or Laryngectomy. — The duties of the nurse are very 
exacting and important in these more important operations. 
The matter of diet is fully considered on page 276, and 
following pages. For three days before the operation the 
patient must have a careful oral and dental cleansing each 
three hours. The mouth and pharynx are gargled with an 
antiseptic solution, Dobell's solution perhaps, and the teeth 



334 



NOSE AND THROAT NURSING. 



are brushed and cleaned also each three hours with a good 
dental paste. Immediately afterwards the mouth and 
pharynx and teeth are sprayed with a solution of argyrol, 
20 per cent., and the teeth crevices are cleaned with an 
argyrol-soaked pledget of cotton. Surgeons believe that the 
after-results depend largely on the care given the patient 
before the operation. A clean mouth prevents sepsis, an 
unclean mouth invites it. 

After the operation the patient is placed in bed with 
the head and chest lower than the feet and abdomen for 
twenty-four hours. As soon as possible after the first forty- 
eight hours the patient should be made to sit up in bed, or 
even get into a chair. This rather rigorous treatment is 
supposed to ward off the post-operative pneumonias which 
frequently complicate these operations. My own belief is 
that the post-operative pneumonia is septic and cannot be 
prevented by posture. 

Besides this the nurse must be alert in watching the 
temperature which should always be rectal, and should 
scrutinize the dressings constantly: a bandage which be- 
comes wet or slimy indicates that the wound is leaking and 
that the deeper sutures are not holding. 

After these operations it is customary to use atropine 
sulphate, % 50 grain, by hypodermic injection, repeated 
often enough (each three hours), to reduce and control the 
oral and pharyngeal secretions. 

Bronchoscopy and Esophagoscopy. 

The instruments for this procedure are all sterilized 
by boiling except the apparatus which holds the electric 
light in the Brunig instrument. The electric light and 
holder are sterilized in alcohol in the Jackson and Brunig 
instruments. The patient is prepared as for an ether oper- 



BRONCHOSCOPY AND ESOPHAGOSCOPY. 335 



ation and a preliminary hypodermic injection of morphine 
sulphate, % grain, is given one hour before the work begins. 
It is well to give a full dose of atropine sulphate (Y 10 o 
grain), also to control mouth or bronchial secretions. 

The patient's head is covered with the usual towel cap 
described on page 275, and the patient is placed on the back 
upon the table. 

The table used in bronchoscopy and esophagoscopy is 
about 5 feet high and on the head end has a shelf level with 
the table, 18 inches long and one-half the width of the table. 
The head of the patient is bent backward over the end of 
the table in such a way that the shelf gives firm support for 
the surgeon's right arm. 

The nurse's duties during this operation are especially 
to count cotton pledgets, and watch the pulse of the pa- 
tient. After the operation the nurse's duties are the usual 
ones following any operation. 



* 



INDEX 

TO 

PART I— EYE NURSING. 



Absorbent cotton, 162 
Accommodation of the eye, 10, 14 
Acetic acid, 72 
Acid, acetic, 72 

boracic, 65, 90 

carbolic, 66 

mineral, 185 

nitric, 185 

sulphuric, 185 

tannic, 73 
Actual cautery, 78 
Acute catarrhal conjunctivitis, 18 
Adrenalin chloride, 74 
Advancement operation, 125 
^Esorcin, 89 

After-nursing of eye operations, 149 
Agnew solution, 73 
Aktol, 72 

Alcohol for sterilizing instruments, 
139 

Allen, R. W., 113 
Alt's strips, 173 
Alum, 72 

pencil, 102 
Alumnol, 72 

Ammonia, burn from, 185 
Anesthesia, general, 136 

local, 85, 139 
Anesthetics, 85 
Anatomy of the eye, 3 

aqueous humor, 8 

choroid, 9 

ciliary body, 10 

conjunctiva, 6 

cornea, 7 

crystalline lens, 8 

eyebrows, 3 

eyelids, 3 

iris, 11 

lacrymal apparatus, 4 

ocular muscles, 5 

optic nerves, 12 

orbits, 13 

retina, 11 

sclera, 7 

uveal tract, 9 

vitreous humor, 8 
Andrews's aluminum shield, 177 

aseptic eye-drop bottle, 94 
Anodynes, 75 



Anterior chamber, 8 
Antisepsis, 17, 129 
Antiseptic dressings, 165 
Antiseptics, 65 
Antitoxin, diphtheritic, 123 
Antitoxins, 44 

Applicators, how to wrap with cot- 
ton, 26 
Aqueous humor, 8 
Argentamine, 72 
Argonin, 72 
Argyria, 71 
Argyrol, 72 
Aristol, 166 

Arrangements for operations, 130 
Arteria centralis retinse, 12 
Artificial eyes, 181 

insertion, 182 

removal, 182 
leech, 90 

light for operations, 130 
Asepsis, 17, 128, 129 
Aseptic dressings, 165 
eye-drop bottles, 94 
Atropine poisoning, 79, 187 
treatment of, 187 
sulphate, 79 
as anodyne, 80 
as mydriatic, 79 
as sedative, 79 

Bacillus, Klebs-Loeffler, 38 

Koch-Weeks, 18 
Bandages, 167 
application of, 167 
double roller, 169 
figure of eight, 171 
single roller, 167 
special, 172 
Baths, 137 

Bichloride gauze, 165 

of mercury, 66 
Binocular vision, 14 
Bleeding after operations, 143, 158 
Blepharitis, 47, 115 
Blisters, 77 
Bloodletting, 90 
Bluestone, 101 
Bonnett's capsule, 13 
Boracic acid, 90, 102 



22 



(337) 



338 



INDEX. 



Borated gauze, 166 
Bottles, eye-drop, 94 
Bowman's membrane, 7 

operation on tear-duct, 140 
Buller's shield, 29 
Burns, 184 

from ammonia, 185 

from carbolic acid, 185 

from lime, 184 

from mineral acids, 185 

Calomel, 67, 76 
Camel-hair brushes, 27, 100 
Camphor water, 90 
Capsule, Bonnett's, 13 

Tenon's, 13 
Carbolic acid, 66 

burns from, 185 
Carbolized gauze, 166 
Caruncula lacrymalis, 6 
Cataract, operation for, 146 

after-care of, 152 
Catarrhal conjunctivitis, 16 
Caustics, 78 

injuries from, 184 
Cautery, actual, 78 

galvano-, 78 

Paquelin, 78 
Chalazion, operation for, 140 
Chalk's eye-drop bottle, 94 
Cheatham's method of using jequir- 

ity, 88 
Chinosol, 70 
Chloride, adrenalin, 74 

sodium, 89 
Chlorine water, 68 
Chloroform anesthesia, 137 
Choroid, 9 
Ciliary body, 10 

muscle, 10 

processes, 10 
Cocain as anesthetic, 85 

as anodyne, 75 

as mydriatic, 83 
Cold applications, 24, 105 
as anodyne, 85 
dry, 105 
moist, 105 
Collargol, 72 
Collodion, 89 

Complications following operations, 

155 

Complications following injections 

of serums and vaccines, 125 
Compress, cold, 105 

hot, 104 
Conjunctiva, 6 

Conjunctivitis, acute catarrhal, 16, 
18, 113, 115 
chronic, 115 
croupous, 38 
diphtheritic, 16, 38, 40 
gonorrheal, 27, 34, 113 
lymphatic, 49 
membranous, 38 



Conjunctivitis, phlyctenular, 49 

trachomatous, 16 

traumatic, 44 

tuberculous, 113 
Contagion, 16 

Contagious eye diseases, 15, 16 
Contusions, injuries from, 186 
Copper stick, 101 
sulphate, 74 

as caustic, 78 

as irritant, 76 
Cornea, 7 

Corrosive sublimate, 66 

Cotton carrier, how to wrap, 26 

wool, 162 
Counter-irritants, 77 
Crede's method, 35, 71 
Croupous conjunctivitis, 38 
Crystalline lens, 8 
Cul-de-sac, application of remedies 
to, 98 

Curetting corneal ulcer, 143 
Cyclitis, 55, 56 

Daturin, 82 
Daviel's spoon, 147 
Daylight for operations, 130 
Decussation of the optic nerves, 12 
Deep infection of the eye, 156 
Delirium after operations, 160 
Detachment of the retina, treatment, 

108, 109 
Diagnostic reactions, 117 
Diaphoresis, 109 
Diet, 110 

Diphtheritic conjunctivitis, 40, 41 
Diplococcus, 15 

Directions for cleansing an eye, 22 
Discharge, contagious, 16 
Discission (needling), 145 
Diseases of the eye, contagious, 16 

noncontagious, 47 
Diseases of the eyelids, 115 
Disinfectants, 65 
Distilled water, 90 
Donders, 63 

Double roller bandage, 169 
Dressings, 133 

antiseptic, 165 

preparation of, 162 

sterilization of, 133, 163 
Drop bottles, 94 

shade, 180 
Drops, 94 
Duboisin, 82 
Duct, lacrymo-nasal, 4 
Dumb-bell bandage, 173 

Ectropion, operation for, 141 
Eczema of the lids, 51 
Emergencies, what to do in, 184 
Emerson, 177 
Endemic, 17 
Ectropion, 48 
Entropion, 159 



INDEX. 



381) 



Enucleation of the eyeball, 143 
Ephedrin, 82 
Epidemic, 17 
Epilation, 48 
Eserin, 84 

Eucaine as anodyne, 75 

as anesthetic, 85, 87 
Eversion of the lids, 25, 97 
Evisceration of the globe, 144 
Exenteration of the orbit, 143 
Expression operation, 141 
Extraction of senile cataract, 146 

after care, 152 
Eye, anatomy of, 3 
Eyeball, 14 
Eye bath, 101 
Eyebrows, 3 
Eye-cup, 101 
Eyelashes, 3 
Eyelids, 3 
Eye sponge, 27 

Faucial diphtheria, 44 

Feeding patients after operations, 153 

Fermentation, 20 

Field of operation, sterilization of, 
139 

Figure of eight bandage, 171 
Fluorescin, 89 
Fomentations, 104 
Food, 110 
Formaldehyde, 68 
Formalin, 67 
Fovea centralis, 12 
Fuchs, 83, 85 

Furniture on operating room, 130 

Galezowski's eye-drop bottle, 94 
Galvanocautery, 78 
Gauze, antiseptic, 165 

bichloride, 165 

borated, 166 

carbolized, 166 

iodoform, 166 
Germicides, 17 
Germ theory of disease, 15 
Glands, lacrymal, 4 

Meibomian, 3 
Glasses, protective, 180 
Glaucoma, 61 

causes of, 63 

predisposing causes of, 63 

treatment, 63 
Globe, enucleation of, 143 

evisceration of, 144 
Gonorrheal ophthalmia, 27 

contagiousness of, 16 
Graefe, 63 

cataract knife^ 147 
Granular lids (trachoma), 16 
expression operation for, 141 
grattage operation for, 141 
Grattage operation for trachoma, 141 
Gruening, 178 



Hallucinations after operations, 151 
Hands, disinfection of, 136 
Heat as anodyne, 75 

dry application of, 104 

moist application of, 104 
Hemorrhage after operations, 143, 158 
Hemostatics, 74 
Hemostatin, 74 
Heurteloup's leech, 90 
Holocaine as anesthetic, 86 

as anodyne, 75 

poisoning, 188 
Homatropin, 82 
Hordeolum (stye), 47 
Hot applications, 31, 103 
Hydrogen peroxide, 68 
Hydrotherapy, 109 
Hygienic surroundings, 27 
Hyoscin, 81 
Hyoscyamin, 81 
Hypodermic injections, 108 

Icebag, application of, 24, 105 
Ice compresses, 24, 105 
Illumination of operating room, 130 
Importance of destroying soiled 

dressings, 33 
Infection, 16 

of the nurse's eyes, 33, 187 
Inferior oblique muscle, 5 

rectus muscle, 5 
Injections, hypodermic, 108 

subconjunctival, 106 
Injuries from burns, 184 

from caustics, 184 

from contusions, 186 

from lime burn, 184 

from penetrating wounds, 186 
Inoculation, 33 

Instruments, sterilization of, 131 
Internal rectus muscle, 5 
Intra-cutaneous tuberculin test, 121 
Intra-ocular tension, 61 
Iodine, 77 
Iodoform, 69, 102 

dressing, 69 

gauze, 166 
Iodol, 69 
Iridectomy, 146 

after-care of, 149 
Irido-choroiditis, 57 
Irido-cyclitis, 55, 56 
Iris, 11 
Iritis, 55 

following operations, 157 
Irrigation of the anterior chamber, 
147 

Irritants, 75 

Isinglass plaster, 152 

Isolation of contagious cases, 33, 34 

Issues, 77 

Itrol, 72 

Jaborandi, 84 
Jequirity, 87 



340 



INDEX. 



Keratitis, phlyctenular, 49, 116 
ulcerative 52 

gonococcic, 114 

pneumococcic, 114 

streptococcic, 114 
Klebs-Loeffler bacillus, 38 
Knies, 63 

Koch's tuberculin, 118 

Koch-Weeks bacillus, 18 

Koller, discoverer of cocaine, 85, 159 

Lacrymal apparatus, 4 
canal, 5 
gland, 4 
sac, 4 

Lacrymal sac inflammation, 113 
Lacrymo-nasal duct, 4 
Lamina fusca, 9 

vitrea, 9 
Lanolin, 89 
Lapis divinus, 76, 101 
Lead subacetate, 74 
Leeches, 90 
Leiter's coil, 105 
Leucoma, 54 

Levator palpebrse superioris mus- 
cle, 3 
Lid retractor, 36 

method of insertion, 100. 
Ligatures, 135 

sterilization of, 135 
Light for operations, 130 
Lime burn, 184 

Lippincott's irrigating tube, 147 
Lister, Lord, 20 
London smoke coquilles, 180 
Lotions, their application, 96 
Lunar caustic, 78 
Lymphatic conjunctivitis, 49 
Lysol, 70 

Macula lutea, 12 
Madarosis, 48 
Masks 174 

Massage of the eyeball, 107 
McCoy's shield, 176 
Mechanical remedies, 107 
Meibomian glands, 3 
Membrana chorio-capillaris, 9 
Membranous conjunctivitis, 38 
Meningitis as cause of panophthal- 
mitis, 63 
Mercury, ammoniated, 76 

bichloride, 66, 76 

biniodide, 67, 76 
Mild chloride, 76 

oxycyanide, 67 

red oxide, 76 

yellow oxide, 75 
Methyl-violet, 69 
Michel, 15 
Micro-organisms, 15 
Mineral acids, burns from, 185 
Miscellaneous remedies, 87 
Moorflelds bandage, 172 



Moro's test, 121 
Mules's operation, 144 
Miiller's circular muscle, 10 
Muscles, ocular, 5 
Mydriatics, 78 
Mydrin, 82 
Myotics, 83 

Nails, care of, 136 
Nasal duct, 4 
Needling operation, 145 

after-care of, 149 
Neisser, 28 
Nitrate of silver, 70 
Nitric acid, burns from, 185 
Noncontagious diseases of the eye, 47 
Normal salt solution, 106 
Nursing after operations, 149 
requirements for, 1 

Ocular muscles, 5 
Ointments, their application, 103 
Opacities of the cornea, 54 
Operating room, 130 
lighting of, 130 
getting ready, 131 

table, 130 
Operations on the eye, 128 
Ophthalmia, catarrhal, 16 

gonorrheal, 27 

neonatorum, 34 
Optic disc, 13 

foramen, 13 

nerve, 12 

tracts, 12 
Ora serrata, 11 
Orbicular muscle, 3 
Orbitis, 13 
Oval eye patch, 163 

Pagenstecher's ointment, 48, 51, 75 
Palpebrse, 3 
Palpebral fissure, 4 
Panas's solution, 67 
Pannus, 87 
Panophthalmitis, 63 
Paquelin's cautery, 78 
Paracentesis of the cornea, 145 

after-care, 149 
Pasteur, 20 

Penetrating wounds of the eye, 186 
Permanganate of potassium, 67 
Peroxide of hydrogen, 68 
Phlyctenular conjunctivitis, 49 

keratitis, 49 
Photophobia, 50, 56 
Physostigmin, 84 
Pilocarpine, 84, 109 
Pink eye, 16 
Piringer, 16 
Plica semilunaris, 6 
Posterior chamber, 8 
Potassium permanganate, 67 
Poultices, 20, 75, 91 
Powders, their application, 102 



INDEX. 



341 



Preparation of field of operation, 136 

of instruments, 131 

of operating room, 130 
table, 130 

of patient, 136 
Pressure bandage, 107 
Preventive treatment, 18, 29 
Prince's forceps, 142 
Prolapse of the iris, 154 
Protargol, 72 
Protective dressings, 29 

glasses, 179 
Ptosis, operation for, 141 
Pupil of the eye, 11 
Purulent choroiditis, 63 
Pyoktanin, 69 
Pyrozone, 69 

Quiet, 111 

Reactions, diagnostic, 117 

positive, 119 

symptoms, 119 
Redressings, 171, 177 
Remedies, their application, 65, 92 
Resorcin, 77 
Rest, 111 

Retina, anatomy of, 11 
Retino-choroiditis, 63 
Retractor, lid, 36 
Ring, 147, 153, 175 
Rochester sterilizer, 134 
Rodent ulcer of the cornea, 52 
Rods and cones, 12 
Roller bandage, 167 
Rubber tipped bulbs, 99 

Salt, 89 

Salves, their application, 103 
Sattler, 15 

Schimmelbusch sterilizer, 133 
Schlemm's canal, 62 
Sclera, 7 
Scleritis, 114 
due to bacillus tuberculosis, 114 
coli, 114 

pneumococcus, 114 

streptococcus, 114 
Sclerotomy, 146 
after-care, 149 
Scopolamine, 81 
Semilunar fold, 6 
Serpiginous ulcer of cornea, 53 
Serums, 113 
Setons, 77 
Shaded glasses, 179 
Shades, 179 
Shields, 174 

Shock, following operations, 159 
Silk ligatures, 135 
Silver nitrate, 70, 78 

substitutes, 71 
Single roller bandage, 168 
Size of the eye, 4 
Sleep, 111 



Snellen reform eye, 181 
Soiled dressings, necessity of de- 
stroying, 33 
Solids, their application, 101 
Solutions, their application, 96 
Spastic entropion, 159 
Special bandages, 172 
Sphenoidal fissure, 13 
Sponges, 27 

Squint, tenotomy for, 142 
Staphylococcus albus, 64 

aureus, 64 
Starch dressings, 174 
Steam disinfection, 134 
Stellwag, 63 

Stephenson's dumb-bell bandage, 173 
Sterilization of bottles, 135 

of dressings, 133 

of droppers, 135 

of drops, 93 

of hands, 136 

of instruments, 131 

of ligatures, 135 

of sutures, 135 
Sterilizers, 133, 134 
Stimulants after operations, 153 
Strabismus, tenotomy for, 142 
Streptococcus pyogenes, 64 
Stroschein's aseptic bottles, 92 
Strychnin nitrate, 108 
Stye, 47, 140 

recurrent, 113 
Subacetate of lead, 74 
Subconjunctival injections, 106 
Subcutaneous test for tuberculosis, 
119 

Sulphate, atropine, 79 

copper, 74, 76 

zinc, 73 
Sulphuric acid, 185 
Superior oblique muscle, 5 

rectus muscle, 5 
Suprarenal extract, 74 
Suprarenatin, 74 
Suprarenin, 74 
Suture material, 133 
Sweat baths, 109 
Sympathetic irido-choroiditis, 57 

irritation, 58 

ophthalmia, 55, 57, 158 
Synechia?, 80 

Syphilis as a cause of eye diseases, 
55 . 

Syringing anterior chamber, 147 

Table for operations, 130 
Tannic acid, 73 
Tarsal cartilage, 3 

ligament, 3 
Tarso-orbital fasciae, 3 
Teale's suction syringe, 147 
Tear passages, 4 

operations on, 140 
Tears, 4 

Temperature of operating room, 130 



342 



INDEX. 



Tenon's capsule, 13 

Tenotomy, 142 

Tension, intra-ocular, 61 

Test-drum, 131 

Theobald's probes, 142 

Therapeutics of the eye, 65, 122 

Tie-patch, 174 

Tincture of iodine, 77 
of opium, 75, 77 

Toxins, 20 

Trachoma, 16 
expression operation for, 141 
grattage operation for, 141 

Traumatic conjunctivitis, 44 

Traumatism due to contusions, 186 
to penetrating wounds, 186 

Trichiasis, 48 

Tuberculin reactions, 117 
focal, 118 
general, 117 

local, 118 i 
Tunica vasculosa, 9 

Ulcer, perforating, 54 

phlyctenular, 50 

roden, 52, 53 

serpiginous, 52, 53 
Uveal tract, 9 

Vaccines, 113 
best syringe to use, 124 
preparing patient for, 124 



Vaccines, reactions from, 124 

focal, 126 

general, 126 

local, 125 
the site for inoculation, 124 
Vaseline, 89 
Venae vorticosse, 10 
Ventilation, 131 
Vinegar, 185 
Vision, binocular, 14 
Vitreous humor, 8 
Vomiting following operations, 
Von Pirquet's test, 120 

Waste disposal, 33 

Water-glass dressing, 174 

Weber, 63 

Wecker, 87 

White of the eye, 7 

precipitate ointment, 76 
Wounds, delayed union of, 155 

infection of, 155 

Yellow ointment, 75 
spot (macula lutea), 12 

Zinc chloride, 69 
oxide, 73 

sulphate, as astringent, 73 
as caustic, 78 
as irritant, 77 
Zone of Zinn, 8, 10 



INDEX 

TO 

PARTS II and III— EAR, NOSE, AND THROAT NURSING. 



Accessory nasal sinuses, 250, 252, 

253, 254, 328 
Acute inflammation of middle ear, 

234 

rhinitis, 293 
Adam's apple, 254 
Adenoid operation, 277 
diet, 295 
tissue, 240 
Anesthesia, general, 263 
hy chloroform, 263 
by ether, 263 
by nitrous oxide, 263 
diet before, 263 
recovery from, 221 
Anesthetics, 221 
local, 259 
by carbolic acid, 260 
by cocaine, 260 
by cold, 260 
by eucaine, 260 
by heat, 259 
by novocaine, 260 
by phenol-camphor, 260 
Anatomy of ear, 189 
of larynx, 254 
of naso-pharynx, 254 
of nose, 249 
of pharynx, 254 
Antitoxin,- diphtheritic, 326 
Antrum, mastoid, 192 
maxillary, 252 
of Highmore, 252 
Application, external, 205 
of leeches, 209 
to nose and throat, 300 
Applicators, winding cotton on, 274 
Arrangement of instrument table, 215 
of living room for operation, 217 
of treatment table, 216 
Artificial drums, 242 
Arytenoid cartilages, 254 
Atresia of external auditory canal, 
230 

Auditory canal, atresia of, 230 
anatomy, 189 
nerve, 194 
Aural polyps, 247 
Auricle, 189 



Balancing power, 196 
Bleeding (see Hemorrhage) 
Blood, vomiting of, 288 
Bodies, foreign, in ear, 231, 232 
Bones of middle ear, 189 
Bougies, 233 

gold, 234 

silvered, 233 
Bronchoscopy, 334 



Canal, external auditory, 189, 190 
atresia of, 230 
incision of, 232, 233 

semicircular, 194 
Cap, rubber, for operations, 275 
Cartilages of larynx, 254 
Cartilage, triangular, 249 
Catarrh, acute, of middle ear, 234 

chronic, of middle ear, 233 
Catheter, Eustachian, 211 
Cerumen, impacted, 229 
Cleft palate operatons, diet, 296 

sepsis in, 294 
Cocaine anesthesia, 260 

poisoning, 260, 261 
Cochlea, 193, 194 

Cold, applications of, 205, 260, 300 

Colds, 31T7 

Cords, vocal, 255 

Cotton wound applicators, 274 

Counter-irritation, 205, 206, 300 

Cricoid cartilage, 254 

Cutaneous eruptions, 230 



Deafness, 241 

Diet after operations, 295 
after adenoid operation, 295 
after cleft palate operation, 275 
after epiglottis operation, 296 
after intubation, 326 
after laryngectomy and laryn- 

gotomy, 278, 333 
after operations on nose and throat, 
295 

after tonsil operations, 295, 331 
before anesthetics, 276 
before operation, 263 
in diphtheria, 317 

(343) 



344 



INDEX. 



Diphtheria, 317 
antitoxin, 320 
bedding, 317 
calomel fumigations, 323 
cultures, 320 
croup kettle, 322 
decubitus, 322 
diet, 322 
disinfection, 317 
general treatment, 323 
infection, 319 
intubation, 324 
isolation, 320 
linen, 317 

local treatment, 322 

management of patient, 317 

quarantine, 321 

receptacles, 318 
Disease of nose, external, 316 

internal, 317 
Disturbance of parts, 287 
Douche, ear, 198, 235 

mouth, 303 

nasal, 269, 270, 271 
for hemorrhage, 270 

pharynx, 303 
Dressing after ear operations, 222 

after furuncles, 227 

after incision of ear canal, 223 

after leeches, 228 

after paracentesis, 232 

after plastics, 222, 302 

after ossiculectomy, 227 

in mastoid cases, 224 
Dressings, preparation of, 219 
Drops, ear, 202, 203, 204 
Drum, • artificial, 192 

of ear, 192, 193, 232 
Dry treatment in ear discharge, 237 
Duct, lacrymal, 249 

Earache, 234 
Ear, anatomy, 189 

atresia, 230 

canal, incision of, 223 

chambers, 189 

chronic catarrh of middle, 233, 238 
douche, 198, 303, 304 
drops, 202, 203, 204, 236 
drums, 192 
eruptions, 230 
external, 189 
foreign bodies, 231 
impacted cerumen, 230, 231 
inflammation of middle, 233, 234 
238 

insects in, 229 
massage, 241 

middle, 192, 193, 234, 238 
operations, dressings, 219 
ossicles, 189 
physiology, 194, 195, 196 
seeds in, 231 
wax, 229 
Edema of larynx, 332 



Emergencies in nose and throat oper- 
ations, 289 
Emphysema of eyelid, 329 
Epiglottis, 255 

operations, diet, 289, 333 
Epistaxis (see Hemorrhage) 
Eruptions on ear, 230 
Erysipelas from leeches, 209 
Esophagoscopy, 334 
Ethmoid cells, 262, 253 

sulci, 253 
Eustachian catheter, 211 

tube, 193, 196 
electrolysis of, 234 
stricture of, 234 
External applications, 207 

Facial nerve, 193 
Foreign bodies in ear, 231 
Fracture of nose, 287, 302, 316 
Frontal sinus, 252, 253 
Furuncles, 227 

Gargles, 314 

General anesthesia, 263 

Hemorrhage, nasal, 279 
control of, 279 
by plugging, 279, 280 
by cotton plug, 279, 280 
by hot douche, 279 
by hydrogen peroxide, 279 
by posterior nasal tampon, 282 
by pressure, 279 
by serum, 287 
by styptics, 279 
by suprarenal extract, 279 

Headache, 289 

Heat, applications of, 259, 300 
Hiatus semilunaris, 249 
Hydrogen peroxide in hemorrhage, 
279 

Hyperemia of labyrinth, 248 
Hypertrophic rhinitis, 328 

Ice applications, 205 

coil, 205 
Incision of eardrum, 232 
Inflammation of ear, 233, 234 
Inhalations, 312 
Insects in ear, 231, 232 
Instruments for mastoid operation, 
243 

preparation of, 243, 244, 264 
sterilization of, 243, 244, 264 
table, arrangement of, 243, 244, 264 

Insufflation of middle ear, 211, 236 

Intubation, 324, 325 
diet after, 326 

Irrigation of ear, 198 
naso-pharynx, 292 
of nose (see Nasal Douche) 

Labyrinth, hyperemia of, 248 
Lacrymal duct, 249 



INDEX. 



345 



Laryngectomy, 298, 333 
I laryngectomy, 298 
Larynx, anatomy, 254, 255 

applications to, 300 

diphtheria (see Diphtheria) 

edema, 332 

operations, 333 

physiology, 256 

spray, 303 

stripping, 278, 264 

tuberculosis, 332 

tumors, 332 
Larvae in ear, 231 
Leeches, application of, 209 

dressing after, 228 

tube for, 209 
Local anesthesia, 259 

applications, 310 
Loss of blood (see Hemorrhage) 
Lozenges, 315 

Massage of ear, 241 
Mastoid antrum, 192 
cases, 242 
duration, 243, 246 
frequency of dressing, 225, 226 
instruments for, 242 
unfavorable symptoms, 244, 245 
operation, dressings, 224, 246 
duties after, 246 
Maxillary antrum, 252 
Meatus, inferior, 250 
middle, 250 
superior, 250 
Membrana tympani, 192, 193 
Meniere's disease, 248 
Middle ear, 192, 193, 234 
Mouth breathing, 227, 230 

douche, 303 
Muscles of larynx, 254 

Nasal chambers, 249 
diphtheria (see Diphtheria) 
discharge, 230 

douche, 270, 271, 272, 303, 304 

hemorrhage (see Hemorrhage) 

sepsis, 274, 285 

splints, 302 

spray, 308 
Naso-pharynx, anatomy, 254 

physiology, 256 
Nerve, auditory, 194 

Nose, accessory sinuses of, 250, 252, 
253 

and throat operations, diet after, 
295 

applications to, 205 

of salve, 205 
diphtheria (see Diphtheria) 
external, 249, 250 
internal, 249 

operations, care of patient after, 
277 

during, 277 



Nose, physiology, 249, 256 

roof of, 249 

septum, 249 

sinuses, 328 

walls of, 250 
Nosebleed, 279 

Olfactory nerve, 250 
Operation for adenoids, 277 
after-treatment, 295 
on mastoid, 242 
of paracentesis, 232 
of tonsillectomy, 278, 329 
preparation for, in ear cases, 213, 
217 

in nose and throat cases, 277 
of living room for, 217, 265 

Oral pharynx, 254 

Organ of Corti, 194, 196 

Ossicles of the ear, 189, 191, 196 

Ossiculectomy, 227 

Oval window, 191 

Paracentesis operation, 232 
Peritonsillitis, 332 
Pharynx, anatomy, 254 

applications to, 300 

diphtheria (see Diphtheria) 

douche, 303 

physiology, 256 

spray, 304 
Physiology of ear, 194, 195 

of larynx, 256 

of naso-pharynx, 256 

of nose, 249 

of pharynx, 256 
Plastic operations, dressings, 302 
Plugging in hemorrhage, 279, 280 

281, 282, 283 
Poisoning by cocaine, 260, 261 

prevention, 261 
Politzer bag, 212, 236 
Politzerization, 211, 236 
Polyp, aural, 247 

Posterior pharynx, applications, SUA 
Postnasal plug see (Postnasal tam- 
pon) 

syringe, 307 

tampon, 279, 280, 281 
Poultices, 207 
Powder blower, 222 

sterilization of, 222 
Powders, application of, 222, 312 
Power of balance, 196 
Preparation of dressings, 219 

of hands, 265, 267 

of instrument table, 243, 244 

of living room, 217 

of operation, 215, 216, 217, 265, 268, 
269 

of politzerization, 211 
of treatment table, 243, 244 
Pressure in hemorrhage, 279 
Purulent inflammation of the middle 
ear, 236, 238 



346 



INDEX. 



Quinsy sore throat, 332 

Reaction after nasal plugging, 285 
Rhinitis, acute, 317 
Roof, nasal, 249 

Room, preparation for operation, 217 
Rubber articles, preparation of, 268 
cap for operation, 268 

Seeds in ear, 231 

Semicircular canals, 194, 196 

Sepsis, 289 
from cotton pledgets, 274, 285 
from nasal operation, 285 
from tonsil operation, 293 
in adenoid operations, 293 
in cleft palate operations, 294 

Septal splints, 301 

Septum of nose, 294 
operation, 301 

Serum treatment in hemorrhage, 
287 

Sinus of Morgagni, 254 
Sinuses of nose, 249 
Skin eruptions, 230 
Snoring in adenoids, 232 
Soothing applications, 300 
Sphenoidal sinus, 253 
Splints, 301 

nasal, 301 

septal, 302 
Spray, 308 

Stacke's protector, 242 
Staphylorrhaphy, diet after, 296 

sepsis after, 294 
Steam applications, 312 
Sterilization, 213, 218, 219, 264 

of field of operation, 213, 264, 265 

of gloves, rubber, 268 

of hands, 265, 267 

of patient, 264, 219, 213, 265 

of powder blower, 222 

of rubber, etc., 266 

of towels, etc., 219, 265 



Stricture of Eustachian tube, 234 
Stripping the larynx, 264, 278 
Stupor, 244, 245, 289 
Styptics, 279 

Suprarenal preparations, 279 
Symptoms, unfavorable in mastoid 

cases, 244, 245, 
Syringe, postnasal, 303 
Syringing the ear, 231 

Table, arrangement for instruments, 
215, 216 
of treatment, 215 
Tampon, nasal (see Hemorrhage) 
Throat operations, care of patient 
after, 277 
during, 277 
Thyroid cartilage, 254 
Tonsillectomy, 278, 329 
diet after, 331 
sepsis after, 278, 329 
Tonsils, 278 

diphtheria of (see Diphtheria) 
Treatment of patient after operation, 
277 

Troches (see Lozenge) 
Tube, Eustachian, 193, 156 

for leeches, 209 
Tuberculosis of larynx, 332 
Tumors of larynx, 332 
Turbinate bodies, 250 

Vaccines, 315 

Ventilation of ear, 196 

Vertigo from ear douche, 198 

from hyperemia of labyrinth, 248 
Vestibule of larynx, 255 
Vocal cords, 255 
Vomiting after anesthetics, 221 

of blood, 330 

Walls of nose, 294 
Wax in ear, 229 



The New York Academy of Medicine 



This book must not be retained for 
longer than one week after the last 
date on the slip unless permission for its 
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